Statement of Principles concerning mitral valve prolapse (Balance of Probabilities) (No. 16 of 2023)

The instrument rests on a narrow set of medical and legal building blocks, each defined in the text.

Definition of the condition: Mitral valve prolapse is defined as a degenerative, structural disorder of the mitral valve apparatus characterised by systolic displacement of an abnormally thickened or redundant mitral leaflet into the left atrium, and must be confirmed by echocardiographic studies (s 7(2)(a)). The definition contains express exclusions: flail mitral valve leaflet, inherited connective tissue disorders including Marfan syndrome, isolated mitral regurgitation in the absence of echocardiographic evidence of mitral valve prolapse, and mitral valve disorder due to rheumatic heart disease (s 7(2)(b)(i)-(iv)). Two diagnostic notes are attached: that mitral valve prolapse is also known as Barlow syndrome or floppy mitral valve syndrome, and that diagnosis does not include displacement or billowing of the anterior leaflet identified only in the 4‑chamber apical echocardiographic view (Notes under s 7(2)).

ICD reference and its limits: The statement notes that mitral valve prolapse attracts ICD‑10‑AM code I34.1, but expressly states that, for the purposes of applying the Statement, the meaning is that given in s 7(2) rather than the code alone (s 7(3)). The instrument also specifies the ICD edition and source it references (s 7(4)). This ensures that code-based indexing is subordinate to the instrument’s textual diagnostic definition.

Scope regarding death: The instrument explicitly includes death from mitral valve prolapse when the terminal event or condition was contributed to by the person’s mitral valve prolapse (s 7(5)). The Schedule provides a non‑exhaustive list of terminal events that are included, such as pneumonia, respiratory failure, cardiac arrest, circulatory failure or cessation of brain function (Schedule 1 terminal event).

Causation standard used by the RMA: The RMA states the standard of its internal view , that, on the sound medical‑scientific evidence available, it is more probable than not that mitral valve prolapse can be related to relevant service (s 8). The instrument itself then lists the factor(s) the RMA considers necessary for a decision-maker to find that, on the balance of probabilities, the condition is connected with service (s 9).

Factors and temporal limits: There is a single enumerated factor: inability to obtain appropriate clinical management for mitral valve prolapse (s 9(1)). Section 10 imposes a relationship-to-service requirement: any factor in s 9 must be related to the person’s relevant service (s 10(1)). Section 10(2) further narrows the application of the inability-to-obtain-management factor to cases of material contribution to, or aggravation of, mitral valve prolapse where the person’s mitral valve prolapse was suffered or contracted before or during the relevant service, but did not arise out of the relevant service (s 10(2)). That temporal limitation is a concrete constraint on the reach of the single factor the RMA sets out.

Interaction with other Statements: If the factor in s 9 refers to an injury or disease that is the subject of another Statement of Principles, the factors in that other Statement apply in accordance with its terms as in force from time to time (s 11). The instrument therefore contemplates cross-references and layered application where causes interact.

Definitions framework: The Schedule1‑Dictionary supplies cross-reference definitions used throughout: MRCA, VEA, relevant service (with specific categories of eligible war service, defence service, peacetime service under MRCA), terminal event, and a pointer that mitral valve prolapse is as per s 7(2). These definitions are operative for determining whether a person’s service meets the relevant-service threshold set by the Acts the Statement serves (Schedule 1).

Collectively, the instrument is concise and conceptually tight: it defines the medical condition narrowly, states the RMA’s evidential view, lists a single causation factor subject to a temporal and relational constraint, and positions the Statement within the VEA/MRCA claim framework.

This Statement of Principles principally affects claimants and decision-makers within the veterans’ entitlements and military compensation systems , that is, current and former members of the Forces and veterans making claims under the VEA or MRCA, and their dependants in death claims. 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, thereby identifying the categories of service that may bring a person within the instrument’s reach (Schedule 1 relevant service).

Claimants with a clinical diagnosis of mitral valve prolapse are directly affected because the instrument sets the medical confines of what will be treated as mitral valve prolapse for claims purposes (s 7(2), s 7(3)). The definition requires echocardiographic confirmation (s 7(2)(a)) and excludes certain pathologies and contexts (s 7(2)(b)). Practitioners, treating clinicians and medical assessors preparing evidence for claims must be aware that an echocardiographic diagnosis consistent with s 7(2)(a) is a defined prerequisite for the condition’s recognition within this Statement.

Decision-makers in the Department of Veterans’ Affairs, medical panels and other tribunals charged with determining entitlement under the VEA and MRCA will use this Statement as the RMA’s causation framework (s 3, s 5, s 8). The instrument identifies the single factor that must be present, inability to obtain appropriate clinical management (s 9(1)); claimants or their representatives who cannot demonstrate that factor, or that it was related to relevant service in the manner required by s 10, may find their claims unsupported by this Statement.

Family members or estates pursuing death claims where mitral valve prolapse contributed to a terminal event are affected because the instrument expressly includes death from mitral valve prolapse within its scope (s 7(5)), and defines terminal event in Schedule 1. The application to death means that situations where mitral valve prolapse contributed to cardiac arrest, respiratory failure or similar terminal events fall within the Statement’s ambit if the causal factor requirements are met.

Medical specialists and echocardiographers are affected in that the diagnostic standard in the Statement is tied to echocardiographic confirmation and excludes certain imaging-limited findings (note to s 7(2)). Records and reports that do not meet the Statement’s diagnostic criteria are unlikely to satisfy the Statement’s threshold.

Finally, the instrument affects the way overlapping or related conditions are treated, because where a factor refers to an injury or disease already covered by another Statement of Principles, the other Statement’s factors apply (s 11). Practitioners managing claims involving multiple cardiac or connective tissue conditions must therefore consider cross-references to other RMA Statements that may govern parts of the causal analysis.

The instrument does not create procedural duties in the sense of enforcement penalties, but it prescribes the factual and medical conditions that must be present for a causal connection to relevant service to be acknowledged under the RMA’s Statement framework. Practically, the key obligations fall on claimants and their advisers to adduce evidence that corresponds to the requirements the RMA has set.

Causation threshold and evidentiary duty: The instrument states that "at least one of the following factors must exist" to conclude, on the balance of probabilities, that mitral valve prolapse or death from it is connected with relevant service (s 9). There is only one factor listed: inability to obtain appropriate clinical management (s 9(1)). That places a practical evidentiary duty on claimants to establish that inability and to link it to relevant service under s 10. The RMA’s view that the link is “more probable than not” is recorded as the basis for the Statement (s 8), but the instrument itself instructs decision-makers to look for the listed factor(s) when applying that view.

Temporal and relational constraint: Section 10 imposes a substantive limitation on the single factor. Any factor in s 9 must be related to the relevant service rendered by the person (s 10(1)). The specific factor in s 9(1) applies only to material contribution to, or aggravation of, mitral valve prolapse where the person’s mitral valve prolapse was suffered or contracted before or during the relevant service but did not arise out of the relevant service (s 10(2)). That condition means a claimant asserting inability to obtain appropriate clinical management must demonstrate both that the mitral valve prolapse pre‑existed or was contracted prior to or during service and that service materially contributed to or aggravated the condition without the condition arising out of service. The instrument thereby circumscribes when the factor can support a causal finding.

Diagnostic limits as substantive constraints: The definitions and exclusions in s 7(2) operate as substantive thresholds for entitlement. A claimant whose cardiac abnormality consists only of a flail leaflet, inherited connective tissue disorder such as Marfan syndrome, isolated mitral regurgitation without echocardiographic evidence of mitral valve prolapse, or rheumatic heart disease are explicitly excluded from being treated as having mitral valve prolapse under this Statement (s 7(2)(b)(i)-(iv)). Note 2 to s 7(2) also places a boundary on echocardiographic interpretation, excluding displacement or billowing identified only in the 4‑chamber apical view. These diagnostic constraints impose an obligation on clinicians and claim preparers to supply evidence that addresses the specific diagnostic definition used by the RMA.

Interaction with other Statements of Principles: Where a listed factor in s 9 refers to an injury or disease for which another Statement of Principles exists, the factors in that other Statement apply (s 11). This creates a duty on claimants to identify and present evidence relevant to any cross-referenced Statements as part of their causation case.

Rights conferred by inclusion: The Statement is presumptively beneficial to claimants who can satisfy its constraints. If a claimant demonstrates the required factor(s) and the required relationship to relevant service, decision-makers are furnished with an RMA statement that supports a finding of service connection on the balance of probabilities (s 8-10). The instrument, by setting the RMA’s view, functions as a predictable evidentiary roadmap for claim preparation.

No punitive or sanctioning measures: The Statement does not, on its face, impose civil or criminal penalties, fines, or other sanctions. It is framed as a medical causation instrument to be applied within the VEA/MRCA claims processes (s 3, s 5). Any procedural rights or review mechanisms remain those provided by the enabling Acts and associated administrative frameworks, not by the Statement itself.

The instrument contains no express penal provisions, fines or criminal sanctions. It is a Statement of Principles made under subsection 196B(3) of the Veterans’ Entitlements Act 1986, and its stated purpose is to set medical factors relevant to claim determinations (s 3). The text does not create an enforcement regime; rather, it operates as an evidentiary and definitional tool within the statutory claim processes that the VEA and MRCA supply (s 5).

Enforcement in practice is administrative and indirect. The Statement is designed to be applied by decision-makers when assessing claims to which s 120B of the VEA or s 339 of the MRCA applies (s 5). The RMA’s view that a condition can be related to service on the balance of probabilities is recorded as based on the sound medical‑scientific evidence available (s 8). This means that the Statement will inform whether the medical link required by the VEA or MRCA is satisfied, but actual enforcement of entitlements, rejection of claims, and implementation of benefits are functions exercised by the relevant administrative bodies under those Acts rather than by the Statement itself.

There is no provision in the instrument for sanctioning non‑compliance by medical practitioners, claimants or agencies with respect to evidence or reporting requirements. The instrument does not prescribe particular documentary or evidentiary procedures; it requires only that mitral valve prolapse be diagnosed as defined (s 7(2)) and that the factor(s) in s 9 be present and related to service per s 10. Consequently, "enforcement" in the narrow sense is the administrative acceptance or rejection of claims based on whether evidence meets the instrument’s specified criteria.

Repeal and replacement: The instrument expressly repeals the earlier Statement of Principles concerning mitral valve prolapse No. 44 of 2014 (s 4). That repeal is an administrative mechanism that removes the prior Statement from active use and replaces it with this instrument. The repeal is the only direct regulatory action contained in the instrument.

In short, the Statement is a non‑punitive administrative instrument that shapes entitlement determinations through definitional and causal criteria rather than by imposing sanctions or penalties. Practitioners should therefore view its "enforcement" effect as mediated through claims decision-making under the VEA and MRCA, not as a standalone enforcement mechanism within the Statement itself.

This Statement is made under and for the purposes of the Veterans’ Entitlements Act 1986 (VEA), pursuant to subsection 196B(3), and it applies to claims to which s 120B of the VEA or s 339 of the Military Rehabilitation and Compensation Act 2004 (MRCA) applies (s 3, s 5). The instrument therefore functions as an RMA‑crafted medical framework to be used within the statutory schemes established by those Acts.

The Schedule defines MRCA and VEA and sets out the meaning of "relevant service" with particular reference to categories of service of interest under the enabling legislation: eligible war service (other than operational service) and 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). Those definitions anchor the Statement’s operational scope to the kinds of service that are recognised by the parent Acts for entitlements and compensation.

Cross-Statement interaction: The instrument anticipates overlap with other Statements of Principles. If a factor in s 9 refers to an injury or disease covered by another Statement determined under subsection 196B(3) of the VEA, then the factors in that other Statement apply in accordance with its terms as in force from time to time (s 11). That is a direct statutory mechanism for harmonising causation assessments where multiple medical conditions are implicated, and it requires practitioners to consult other relevant Statements when a listed factor invokes a separately addressed injury or disease.

ICD coding and external classification systems: The instrument refers to the ICD‑10‑AM classification, noting that mitral valve prolapse attracts ICD‑10‑AM code I34.1 (s 7(3)) and specifying the edition and source of the code referenced (s 7(4)). However, the instrument makes clear that the RMA’s textual definition in s 7(2) governs the condition’s application for claims purposes, not the ICD code alone (s 7(3)). This means that while ICD coding may facilitate record-keeping and cross-system indexing, the Statement’s substantive diagnostic definition takes precedence where there is any divergence.

Interaction with clinical practice standards and evidence: The instrument requires echocardiographic confirmation for diagnosis (s 7(2)(a)) and places limits on what echocardiographic findings constitute mitral valve prolapse for the purposes of these claims (note to s 7(2)). The Statement therefore intersects with clinical standards of cardiology and echocardiography by prescribing a particular evidentiary threshold. While the instrument does not itself set clinical practice standards or licensing obligations, it aligns administrative claim outcomes with specified clinical findings.

Administrative procedure and decision-making law: The Statement does not detail procedural provisions such as review rights, avenues of appeal, or administrative decision-making processes; those mechanisms exist in the VEA and MRCA (s 3, s 5). The Statement supplies a medical causation framework that decision-makers apply within the procedural and review frameworks provided by the Acts. Practitioners must therefore operate with an eye to how this Statement’s requirements will be used in the wider statutory decision-making and review regime, even though those procedures are not set out in the Statement itself.

In essence, the instrument is an adjunct to the VEA and MRCA: it is an RMA determination about medical causation that is to be applied within the statutory claims processes established by those Acts, with explicit cross-referencing to other RMA Statements and a defined relationship to clinical classification systems like ICD‑10‑AM.

The instrument contains a single explicit historical action: it repeals the prior Statement of Principles concerning mitral valve prolapse No. 44 of 2014 (Federal Register of Legislation No. F2014L00473) made under subsection 196B(3) of the VEA (s 4). The text records its own date and commencement: dated 27 February 2023 and commencing 27 March 2023 (title and s 2). Beyond those items, the instrument does not list any prior amendments, transitional provisions, or schedules of change beyond the repeal.

What the instrument documents therefore is a replacement of the 2014 Statement with this 2023 Statement. The mechanism is clear: the Repatriation Medical Authority made a new Statement under its subsection 196B(3) power and expressly repealed the earlier Statement (s 3, s 4). The new Statement’s definitions and factors are to operate from its commencement date (s 2).

The Schedule and definitions given in the current instrument are the operative definitions for application from commencement. No savings, grandfathering or transitional treatment of claims decided under the previous Statement is provided within the instrument itself. The instrument does not state whether claims lodged prior to commencement but decided after it will be assessed according to the 2014 or 2023 Statement. Practitioners should therefore take careful note that the 2014 Statement has been repealed by s 4 and that the 2023 Statement is in force as of its commencement date (s 2).

Because the instrument does not include an amendment chronology beyond repeal of the 2014 Statement, users who require the legislative or administrative history of how the RMA’s approach evolved across iterations will need to consult external legislative records, prior Statements, and RMA explanatory materials. The Statement itself does not provide that record.

The instrument does not record any litigation history. It contains no references to court decisions, tribunal findings, or legal challenges to either this instrument or the prior Statement that it replaces. There are no cases, proceedings, or judicial reviews named or summarised in the text.

Practically, that absence means the Statement as made sets out the RMA’s medical view and factors without any attached narrative of how those factors have fared in litigation. The instrument is silent about whether any prior or subsequent determinations under the VEA or MRCA that relied on the older 2014 Statement were challenged, litigated, or considered in case law. It likewise contains no indication of judicial interpretation of the particular definitions or the temporal constraints in s 10.

For practitioners, the absence of litigation references within the instrument itself is a signal to check other sources for any judicial or tribunal engagement with these issues. The Statement replaces the 2014 instrument (s 4), but this replacement is presented without commentary on precedent. If precedential questions or interpretative disputes arise in application, they will be resolved through the ordinary channels of claim review and litigation under the VEA and MRCA and related administrative and judicial processes, none of which are described in this document.

Because the text provides no litigation history, readers cannot infer from the instrument whether courts or tribunals have accepted or rejected RMA formulations in similar Statements. The instrument’s silence on litigation history means that reliance on its definitions and factors should be accompanied by independent review of relevant tribunal and court decisions outside the instrument where practitioners require guidance on how decision-makers and courts have treated comparable RMA Statements.

Several concrete, potentially surprising constraints are embedded in the instrument and are likely to be practical pitfalls for claimants and advisers unless addressed in claim preparation.

Narrow diagnostic definition and express exclusions: The instrument defines mitral valve prolapse with a strict echocardiographic requirement and specific exclusions (s 7(2)(a), s 7(2)(b)). A claimant whose record shows only isolated mitral regurgitation without echocardiographic confirmation of mitral valve prolapse, or who has a flail leaflet, rheumatic heart disease, or an inherited connective tissue disorder such as Marfan syndrome, will not meet the instrument’s definition (s 7(2)(b)). Note 2 narrows the diagnostic interpretation further by excluding displacement or billowing identified only in the 4‑chamber apical view. Failure to match the instrument’s diagnostic language precisely is likely to result in the Statement being inapplicable.

Single factor, narrow scope: The instrument lists only one factor that must exist for a connection to service: inability to obtain appropriate clinical management for mitral valve prolapse (s 9(1)). Practitioners must not assume a broad range of causal factors are accepted by the RMA for this condition. If a claimant cannot establish that inability to obtain appropriate clinical management occurred and that it is related to relevant service as required by s 10, the Statement as drafted will not support a causal finding.

Temporal limitation on the factor: The inability-to-obtain-management factor is expressly restricted to material contribution to, or aggravation of, mitral valve prolapse where the person’s mitral valve prolapse was suffered or contracted before or during relevant service but did not arise out of the relevant service (s 10(2)). That wording creates a potentially counterintuitive situation: where mitral valve prolapse arose out of relevant service, this particular factor does not apply. Claimants whose condition clearly arose out of service will need to consider whether another Statement of Principles applies, because s 10(2) removes the s 9(1) factor’s applicability in those circumstances.

ICD coding is not determinative: Although the instrument notes the ICD‑10‑AM code associated with mitral valve prolapse (I34.1) and specifies the edition (s 7(3)-(4)), it states that the meaning for the Statement is the textual definition in s 7(2). Reliance solely on diagnostic coding in medical records without ensuring the echocardiographic criteria and exclusions align with s 7(2) risks failing to meet the Statement’s standard.

Death claims require contribution to a terminal event: Death from mitral valve prolapse is included only where the terminal event or condition was contributed to by the person’s mitral valve prolapse (s 7(5)). The Schedule lists examples of terminal events. Mere presence of prior mitral valve prolapse without evidence it contributed to the terminal event may not satisfy the Statement for death claims.

Cross-references to other Statements: If the single factor in s 9 refers to an injury or disease that is covered by another Statement, then the factors in that other Statement apply (s 11). A factor that appears to point to a separate condition may therefore bring in the requirements of another Statement, potentially expanding evidentiary demands. Failure to identify relevant cross-references will undermine claim completeness.

No procedural detail or transitional guidance: The instrument repeals the 2014 Statement but provides no transitional or savings provisions (s 4). The Statement also does not articulate how decision-makers should handle claims initiated before commencement. Practitioners should not assume transitional arrangements exist within this instrument.

Ambiguity in what constitutes "inability to obtain appropriate clinical management": The instrument names inability to obtain appropriate clinical management as the single factor (s 9(1)) but does not define the term. That absence leaves open questions about temporal scope, geographical or financial barriers, adequacy of alternative management, and what evidence suffices to prove inability. These matters will need to be addressed in evidence and, if disputed, through decision-maker interpretation or external review.

Limited recourse in the instrument: The Statement contains no enforcement, penalties, or internal appeals mechanism; it is a medical framework to be applied by decision-makers under the VEA/MRCA (s 3, s 5). Practitioners should therefore ensure claims are robust against the Statement’s specific criteria rather than expecting remedial mechanisms to rectify evidentiary gaps in the Statement itself.

Overall, the combination of a narrow diagnostic definition, a single and temporally constrained causation factor, and the absence of procedural detail are the key practical "gotchas" embedded in the document.

Compliance in this context means presenting a claim with evidence tailored to the Statement’s substantive definitions and factor requirements so that a decision-maker applying this Statement can find the necessary elements on the balance of probabilities.

Match the diagnostic definition precisely. Obtain and supply echocardiographic studies that confirm the degenerative structural features the Statement requires: systolic displacement of an abnormally thickened or redundant mitral leaflet into the left atrium, documented by echocardiography (s 7(2)(a)). Ensure reports address the specific exclusion in Note 2 and avoid relying on imaging limited to the 4‑chamber apical view if that is the only positive finding (note to s 7(2)). Make sure the echocardiographic report addresses whether findings correspond to mitral valve prolapse as defined in s 7(2) rather than merely citing an ICD code, because the Statement directs application of the textual definition over the code (s 7(3)).

Address exclusions directly. If the clinical record suggests an alternative explanation such as flail leaflet, inherited connective tissue disorder, isolated mitral regurgitation without echocardiographic confirmation of prolapse, or rheumatic heart disease, assemble opinion evidence that clarifies why those excluded diagnoses do not apply or, if they do, consider whether relief might be sought under a different Statement relevant to the excluded condition (s 7(2)(b)(i)-(iv), s 11).

Prove the claimed factor: inability to obtain appropriate clinical management. The single operative factor is inability to obtain appropriate clinical management for mitral valve prolapse (s 9(1)). Supply contemporaneous evidence that documents attempts to obtain management, barriers encountered, and the impact of that inability on the condition. Because the instrument does not define "inability to obtain appropriate clinical management", evidence should be structured to show the objective circumstances: dates, locations, referrals, wait times, denials, unavailability of services, or other barriers to clinically appropriate care. Expert medical opinion should link that inability to material contribution or aggravation of the condition where necessary.

Satisfy the temporal and relationship requirement in s 10. Section 10(1) requires that any factor in s 9 be related to the relevant service. Section 10(2) further restricts the factor to situations where the mitral valve prolapse was suffered or contracted before or during relevant service but did not arise out of it. Therefore, to comply, assemble evidence showing the timing of onset or diagnosis relative to the period of relevant service (as defined in the Schedule) and an expert opinion addressing whether service materially contributed to or aggravated the pre‑existing condition without being the cause that gave rise to it. Medical timelines, service records and treating clinician reports will be necessary.

If death is claimed, show contribution to the terminal event. For death claims under s 7(5), adduce medical and forensic evidence that mitral valve prolapse contributed to the terminal event (for example, cardiac arrest or circulatory failure as listed in Schedule 1). Post‑mortem reports, treating histories and expert opinions should explicitly address contribution rather than mere presence of the condition.

Consider cross-referenced Statements. If any aspect of the claimed factor points to another disease or injury for which an RMA Statement exists, identify and comply with that other Statement’s requirements because s 11 brings those factors into play. This may expand the documentary and opinion evidence necessary.

Record-keeping and contemporaneous documentation. Because the Statement’s operative factor concerns inability to obtain clinical management, contemporaneous records of attempts to seek care, correspondence with service medical facilities, referrals and denials, and all echocardiographic reports and cardiology opinions will be central. Decision-makers will be applying this Statement against the available evidence, so comprehensive records increase the chance that the instrument’s narrow criteria can be demonstrated.

Engage experts who will address the Statement head-on. Medical experts preparing medico-legal reports should be instructed to address each element of the Statement: the precise echocardiographic criteria for diagnosis, the exclusions, whether the mitral valve prolapse was suffered or contracted before or during relevant service, whether it arose out of service, whether there was inability to obtain appropriate clinical management and whether that inability materially contributed or aggravated the condition. Where death is claimed, experts should explicitly opine on contribution to the terminal event (s 7(5)).

Be mindful of the repeal of the 2014 Statement. The 2014 Statement has been repealed by s 4. Use the diagnostic, factor and relationship language in this 2023 Statement for claims lodged on or after its commencement; do not rely on the 2014 text.

Finally, assemble evidence with the Statement’s narrow language in mind. Because the Statement provides a tight set of requirements, compliance is achieved by mapping medical and service evidence to those requirements precisely and explicitly, rather than by relying on broader cardiology narratives that do not address the RMA’s specified elements.