Statement of Principles concerning multiple osteochondromatosis (Balance of Probabilities) (No. 44 of 2023)

The instrument builds around a narrow set of legal and medical concepts, each defined or constrained in the text.

1. Definition of the condition. Multiple osteochondromatosis is defined precisely in medical terms (s 7(2)). The instrument excludes two distinct conditions,synovial osteochondromatosis and enchondromatosis,so diagnosis must map onto the statutory definition rather than a mere ICD‑10 label (s 7(3)-(4)). The instrument therefore separates semantic coding (ICD‑10‑AM Q78.6) from the statutory meaning given in the subsection (s 7(3)-(4)).

2. Standard of proof. The instrument is explicit that the Repatriation Medical Authority's view is that it is "more probable than not" that MO and death from MO can be related to relevant service (s 8). The instrument's title also includes "(Balance of Probabilities)". This places the Statement within the civil standard of proof used for factual connection in claims processes that rely on Statements of Principles.

3. Factual factors. The instrument contains one substantive factor that "must exist" to establish a connection: the inability to obtain appropriate clinical management for MO (s 9(1)). The instrument sets this as a necessary factual element for a causal/legal nexus under the Statement.

4. Temporal and causal limits. Section 10(2) confines application of the inability‑to‑obtain‑care factor to situations where MO was "suffered or contracted before or during (but did not arise out of)" the person's relevant service. This imposes a temporal and causal boundary: the factor is aimed at material contribution or aggravation of a pre‑existing or contemporaneous‑but‑not‑caused‑by‑service condition.

5. Relevant service. The instrument adopts statutory categories of relevant service in its Dictionary: eligible war service (other than operational service) and defence service under the VEA, and peacetime service under the MRCA (Schedule 1). The label "relevant service" triggers the nexus requirement in s 10(1).

6. Death and terminal events. Death from MO is defined to include deaths where the person's MO contributed to a terminal event or condition, and the Dictionary lists examples of terminal events such as pneumonia, respiratory failure, cardiac arrest, circulatory failure, and cessation of brain function (s 7(5); Schedule 1).

7. Cross‑references to other Statements. Where a factor in this Statement refers to an injury or disease addressed by another Statement of Principles, the other Statement's factors apply in accordance with that Statement as in force from time to time (s 11). This preserves cross‑instrument consistency where co‑morbidities or cross‑referenced conditions are involved.

These concepts structure the evidential and legal pathway for a claim under the VEA/MRCA frameworks that depends on this Statement. The instrument privileges a specific pathway to connection,failure to obtain appropriate clinical management,and circumscribes it temporally and causally.

The instrument applies to persons making claims under statutory claim pathways specified in s 5: claims to which section 120B of the VEA or section 339 of the MRCA apply. It therefore affects claimants whose entitlement claim for MO or death from MO is processed under those provisions. The Schedule identifies the statutory terms used in the Statement: VEA, MRCA and relevant service (Schedule 1).

Practitioners and decision‑makers involved in veteran and defence compensation systems will be directly affected because the Statement sets the factors that must exist before it can be said that, on the balance of probabilities, MO or death from MO is connected with relevant service (s 9). Administrative officers, medical assessors, lawyers representing claimants, and clinical witnesses will all rely on the Statement to frame the factual and medical questions required for causation as it relates to service.

From a claimant perspective, the instrument primarily affects two groups:

• Persons diagnosed with multiple osteochondromatosis who experienced the condition before entering service or who suffered or contracted it during service but where it did not "arise out of" service. For such persons, the single operative factor is inability to obtain appropriate clinical management for MO. The factor must be related to relevant service under s 10(1) and meet the temporal/causal constraint in s 10(2).

• Dependants or estates of persons whose death involved contribution from MO. The instrument treats death as including deaths where MO contributed to a terminal event (s 7(5)). Therefore, claims concerning death require evidentiary linkage that MO materially contributed to the terminal event or condition listed or of a similar nature.

The instrument excludes persons whose condition falls within the expressly excluded disorders,synovial osteochondromatosis and enchondromatosis (s 7(2)(b)). It also implicitly limits pathways for claims where MO "arose out of" relevant service: the factor in s 9(1) does not apply in those circumstances (s 10(2)), and there are no other factors in this Statement to cover such a pathway. In those cases, claimants and advisers must look to other legal mechanisms (for example other Statements of Principles or provisions within the VEA/MRCA) but this instrument itself does not create an alternative factor.

Finally, the Statement affects medical experts asked to provide opinions in claims. Diagnosis must track the instrument's definition rather than rely solely on the ICD code: the instrument explicitly states that while MO has ICD‑10‑AM code Q78.6, the meaning for this Statement is the textual definition in s 7(2) (s 7(3)-(4)).

The instrument does not create administrative duties or rights in the way primary statutes do, but it prescribes the factual requirements that decision‑makers and claimants must meet to establish a service connection for MO or death from MO within the claim pathways identified (s 5). Its operative legal effect is to inform the application of the balance‑of‑probabilities standard when deciding whether MO is connected with relevant service, by specifying the factors that "must exist" (s 9).

Duties of relevance implicit in the instrument include:

• For decision‑makers: to apply the Statement when determining service connection for MO or death from MO on claims to which s 120B VEA or s 339 MRCA apply, assessing whether at least one of the Statement's factors exists on the balance of probabilities (ss 5 and 9; s 8). The Statement is the Authority's determination under s 196B(3) of the VEA, and it is the instrument that decision‑makers use to map medical/scientific evidence to legal conclusions.

• For medical assessors and experts: to diagnose the condition in the terms the Statement uses. The Statement makes clear that the statutory meaning of MO is the textual definition in s 7(2), not the ICD‑10‑AM label alone (s 7(3)-(4)). An expert opinion that the claimant's condition meets the statutory definition is therefore material.

• For claimants and their representatives: to adduce evidence that the specified factor(s) exist and that the factor(s) are related to the person's relevant service (ss 9-10). Where the claim relies on s 9(1), evidence will need to establish inability to obtain appropriate clinical management and tie that inability to the relevant service period and the defined types of relevant service (Schedule 1).

Rights established or affected by the Statement are primarily evidential and procedural:

• Claimants gain the ability to rely on the Authority's concluded factor(s) to establish service connection if they can demonstrate the facts required by the Statement. The Statement identifies a route to connection via inability to obtain appropriate clinical management (s 9(1)).

• Where the Statement refers to another Statement of Principles, the claimant has the right to have that other Statement applied in accordance with its terms, as in force, if the factor in this Statement refers to an injury or disease covered by that other Statement (s 11).

The instrument also sets limits that operate as constraints:

• The instrument restricts the s 9(1) factor to cases where MO was suffered or contracted before or during (but did not arise out of) relevant service (s 10(2)). That temporal/causal constraint is effectively a disqualifying provision for use of the s 9(1) factor in other situations.

• The definition exclusions (s 7(2)(b)) remove certain diagnoses from coverage under this Statement. The ICD code is given as a cross‑reference but the statutory definition in s 7(2) controls (s 7(3)-(4)).

Finally, the instrument does not set penalties, administrative remedies, or entitlement quantum. It is a standards‑setting instrument: it prescribes what factual elements must be present to establish the service link on a balance‑of‑probabilities basis. How the VEA or MRCA applies entitlements after such a finding is beyond the text of this instrument.

This Statement of Principles does not itself create criminal offences or specify financial penalties. Its legal function is evidentiary and determinative within the claims framework: it tells decision‑makers which factors must be present to find, on the balance of probabilities, that MO or death from MO is connected with relevant service (s 9). Enforcement in the usual sense is carried out within the administrative adjudication processes established by the VEA and MRCA; this instrument supplies the criteria those processes must apply.

Key enforcement‑related mechanics, as derived from the instrument, are:

• Administrative application. The Statement will be applied by the bodies and decision‑makers processing claims under s 120B VEA and s 339 MRCA (s 5). The instrument thereby affects how those decision‑makers determine causation or connection. If, on application of the Statement, the required factor(s) are found to exist and relate to relevant service, that finding will feed into whatever entitlements or remedies the VEA or MRCA provide for a connected condition. The instrument itself does not state those consequences.

• Evidentiary threshold. The Statement sets the factual threshold (balance of probabilities) and enumerates the factor(s) that must be present. A failure to satisfy the Statement's factors will be a lawful basis for rejection of a service connection claim for MO under the VEA/MRCA pathways referenced. Conversely, a finding that the factors exist may be obligatory for the decision‑maker in assessing connection, depending on the statutory scheme of the VEA/MRCA and the administrative process which is not reproduced in this instrument.

• Cross‑instrument application. The instrument anticipates interplay with other Statements of Principles: where a factor in this Statement refers to an injury or disease subject to another Statement, the other Statement's factors apply (s 11). The operational effect is that enforcement of the evidentiary standard for related conditions will rely on the current terms of those other Statements.

• Repeal and replacement. The instrument repeals the 2015 Statement for MO (s 4). Claims made after commencement will be assessed against the new Statement; decision‑makers must therefore apply the 2023 Statement rather than the 2015 instrument from 23 May 2023 onward. Administrative practice and ongoing claims may be affected by this replacement.

Because the Statement is not an enactment of penalties, the enforcement risk lies in the administrative outcome of claims and decisions under the VEA and MRCA. The instrument defines what must be proved to obtain a favourable administrative determination under the specific statutory claim provisions it references (s 5). Any penalties for false statements, fraudulent claims, or similar conduct would arise under other statutory regimes; they are not created or described in this Statement.

This Statement is made under subsection 196B(3) of the VEA (s 3) and expressly applies to claims to which s 120B of the VEA or s 339 of the MRCA apply (s 5). It therefore functions within the statutory architecture of the VEA and MRCA by supplying the medical‑scientific factors used to determine service connection for MO­‑related claims.

Specific interactions and cross‑reference mechanics in the instrument:

• Primary statutory authority. The Repatriation Medical Authority’s power to make Statements of Principles derives from the VEA; this instrument is such a Statement under s 196B(3) (s 3). The instrument therefore must be read and applied in the context of the decision‑making provisions of the VEA and the MRCA. The instrument does not set or alter the jurisdictional or procedural provisions of those Acts; instead it provides the medical factors decision‑makers use when applying the Acts’ claim provisions.

• Application to claim provisions. By stating that it applies to claims to which s 120B VEA or s 339 MRCA apply (s 5), the instrument ties its operative effect to determinations made under those statutory sections. It is not a freestanding entitlement; its role is evidentiary , a decisional input used by those adjudicating claims under those sections.

• Cross‑Statement consistency. Section 11 creates a mechanism for cross‑instrument interaction: if a factor in this Statement refers to an injury or disease covered by another Statement of Principles, the other Statement's factors apply in accordance with that other Statement as in force from time to time. This allows overlapping or related conditions to be assessed using the most current Statements relevant to them and ensures that the Repatriation Medical Authority’s Statements operate as an integrated set rather than isolated instruments.

• Medical classification reference. The Statement references the ICD‑10‑AM code Q78.6 as the diagnostic code associated with MO but then makes clear that the statutory meaning in s 7(2) governs application of the Statement (ss 7(3)-(4)). The ICD reference is therefore one input among definitional text; it does not supplant the instrument's textual definition.

• Temporal and causal limitations relative to service law. Section 10(2) places temporal and causal limits on the only listed factor, tying it to MO that was suffered or contracted before or during (but not arising out of) relevant service. This creates an interaction with how the VEA and MRCA treat "arising out of" service and material contribution/aggravation in those Acts; the Statement supplies a specific causation pathway that must be read together with the statutory causation concepts in the primary legislation.

• Repeal of prior Statement. The 2015 Statement for MO is repealed (s 4). The repeal changes the network of Statements that decision‑makers must consult for MO claims from the date of commencement. This is a direct interaction: prior determinations and practice notes that relied on the 2015 instrument now must be reassessed against the 2023 instrument.

What the instrument does not do is change or restate the operative entitlements, processes for appeal, or remedies that the VEA or MRCA provide. It also does not create new offences, nor does it amend the substantive definitions within those Acts. Its effect is to supply the medical‑scientific framework which the primary statutes incorporate by reference when determining service connection.

This Statement of Principles is No. 44 of 2023 and is dated 24 April 2023, with commencement on 23 May 2023 (ss 1-2). Section 4 expressly repeals the Statement of Principles concerning multiple osteochondromatosis No. 44 of 2015 (Federal Register of Legislation No. F2015L00009). The instrument therefore replaces the earlier 2015 Statement for this condition.

The instrument contains no other provisions amending earlier legislation; it is a standalone Statement made under subsection 196B(3) of the VEA (s 3). The Dictionary in Schedule 1 defines key terms used in the Statement, including MRCA, multiple osteochondromatosis (by reference back to s 7(2)), relevant service, terminal event, and VEA (Schedule 1). The inclusion and structure of the Dictionary is part of the instrument’s internal drafting rather than a cross‑reference amendment to other statutory texts.

Because the Statement is a delegated instrument under the VEA, its amendment history will be the record of Statements that replace earlier versions. As of its commencement date, the 2015 Statement is repealed and superseded. The instrument itself contains no transitional provisions specifying how claims that were in progress at the time of repeal are to be treated; the only explicit temporal provision is the commencement date (s 2) and repeal (s 4). Decision‑makers must therefore apply the 2023 Statement to claims to which it applies from and after commencement. Any subsequent amendments to this Statement, or its repeal, would themselves be effected by instruments under the same statutory power; none are set out in this text.

When researching the legislative history in administrative or litigation contexts, practitioners should note:

• The immediate predecessor instrument is identified and repealed (s 4).

• The Statement is made under subsection 196B(3) of the VEA (s 3); any changes to the Repatriation Medical Authority’s power would be effected in the primary legislation rather than in this subordinate instrument.

• The instrument's definitions and cross‑references (Schedule 1) are self‑contained; the Dictionary governs the Statement’s internal operation unless a subsequent instrument alters it.

No other amendment entries, commencement variations, or schedules of revocation are contained in the instrument itself.

The instrument contains no record of litigation. It does not cite cases, nor does it indicate any judicial consideration of this specific Statement of Principles (the text lists no litigation history). The Statement functions as the Repatriation Medical Authority’s medical‑scientific determination and is intended to be used within the statutory claim processes of the VEA and MRCA.

Potential points that could give rise to litigation, based on the instrument’s content, would include disputes over interpretation and application of its defined terms and factors, examples being:

• The meaning of "inability to obtain appropriate clinical management" in s 9(1). The phrase is not further elaborated in this instrument; disputes could arise about what facts meet this threshold, such as whether inability must be attributable to service conditions, availability of care, or other causes. Section 10(1) requires that the existence of the factor be related to relevant service, and s 10(2) adds temporal and causal constraints; these cross‑references would likely be the focal point of interpretative disputes.

• The application of s 10(2)’s clause "did not arise out of" relevant service. Whether a condition "arises out of" service is a causal determination within the statutory scheme and may require interpretation in particular fact patterns. Because s 10(2) confines the s 9(1) factor to conditions that did not arise out of service, litigated questions could involve whether MO in a given case arose out of service or was merely pre‑existing or contemporaneous.

• The degree of contribution required for "material contribution to, or aggravation of" under s 10(2). The instrument does not quantify "material"; differences of expert opinion about materiality could produce disputes that enter administrative review or judicial review processes.

• The evidentiary standard and how the Authority’s Statement interacts with decision‑makers under s 120B VEA and s 339 MRCA (s 5). Litigated issues could include whether decision‑makers correctly applied the Statement, whether they properly considered cross‑referenced Statements under s 11, or whether the Statement was applied retroactively in a way inconsistent with prior practice.

None of these litigation scenarios are recorded in the text; they are points where the instrument’s language is sufficiently terse that contested interpretation would be likely in practice. Practitioners should therefore note the absence of case law in the instrument and treat interpretative questions as matters to be resolved in the administrative decision process and, if necessary, by review bodies or courts in the relevant statutory avenues.

The instrument’s brevity and narrow structure produce a number of practical pitfalls for claimants, advisers, decision‑makers, and medical experts. Below are concrete issues, with citations to the relevant provisions.

1. Single operative factor. There is only one listed factor that "must exist" to support a finding of connection: inability to obtain appropriate clinical management for MO (s 9(1)). If a claimant cannot establish that factual element, the Statement offers no alternate pathway to connection within its text. Practitioners should not assume that other, unstated factors are permitted under this Statement; the instrument requires at least one of the listed factors (s 9).

2. Temporal and causal constraint. The s 9(1) factor applies only to material contribution to, or aggravation of, MO where the MO was "suffered or contracted before or during (but did not arise out of) the person's relevant service" (s 10(2)). That means:

• If MO arose out of relevant service (i.e. was caused by service), the s 9(1) factor does not apply, and the Statement contains no other factor for such a causal pathway (s 10(2)).

• Claimants who allege MO attributable directly to service should not rely on s 9(1) of this Statement as their evidential route; they must identify other legal and evidential avenues within the VEA/MRCA framework or other Statements (s 11 might be relevant if other Statements cover related injuries).

3. Definition trumps ICD code. Although the document notes the ICD‑10‑AM code Q78.6 is associated with MO, subsection 7(3) states that "in applying this Statement of Principles the meaning of multiple osteochondromatosis is that given in subsection (2)." Consequently, an ICD code alone is not dispositive; the medical diagnosis must align with the statutory definition in s 7(2). Practitioners relying solely on coding from hospital records may be surprised if the clinical description does not match the textual definition.

4. Exclusions in definitional text. Synovial osteochondromatosis and enchondromatosis are expressly excluded from the definition of MO (s 7(2)(b)). Records that use overlapping terminology or that record mixed pathology require careful analysis to ensure the excluded conditions are not being conflated with MO.

5. Vague threshold language. "Inability to obtain appropriate clinical management" is not further defined here (s 9(1)). The phrase raises questions about what constitutes "appropriate," what attempts to obtain care must be shown, whether the inability must be caused by service circumstances, and what role cost, geographic access, or system failure play. Section 10(1) requires that the existence of the factor be related to relevant service, but the instrument does not set out the permissible causal links. Expect adjudicators to request detailed evidence.

6. Death linkage involves contribution to a terminal event. The Statement treats death from MO as including deaths where MO contributed to a terminal event (s 7(5)). The Dictionary lists examples of terminal events (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function). Practitioners should not equate any death of a person with MO as necessarily covered; they must show contribution of MO to the terminal event. The instrument does not define "contributed to" or set a threshold for contribution.

7. Interaction with other Statements. Section 11 pulls in other Statements of Principles where the factor refers to an injury or disease covered by another Statement. This can be a source of complexity: a factor in this Statement might trigger requirements in another Statement that are more extensive or different in scope. Practitioners must check for cross‑references.

8. No procedural detail on evidential burden. The instrument sets the balance‑of‑probabilities standard (s 8) but supplies no procedural steps, evidentiary checklists, or prescriptive documentation requirements. Practitioners must map the Statement’s elements onto the procedural rules and evidentiary standards of the VEA/MRCA claims process.

9. Repeal timing. The 2015 Statement is repealed (s 4). For ongoing matters, it may not be immediately obvious whether claims started before commencement should be adjudicated under the old or new Statement; the instrument contains no transitional wording. Administrative practice and policy documents may clarify this, but the instrument itself does not.

10. Narrow coverage of "relevant service". The Dictionary defines relevant service by reference to specific categories (eligible war service other than operational service; defence service other than hazardous service and British nuclear test defence service under the VEA; peacetime service under the MRCA) (Schedule 1). Claims that involve other categories of service or that fall outside those listed categories will not be covered by the linkage requirements in this Statement.

In short, the instrument is precise in some respects and terse in others. The most immediate operational "gotchas" are the single, narrowly framed factor; its temporal/causal constraint; the textual definition of MO that overrides coding; and the lack of definition for "inability to obtain appropriate clinical management." Advisers must therefore gather factually specific evidence and not rely on presumptions or ICD coding alone.

Compliance in this context means assembling the factual and medical material that will satisfy the Statement’s requirements so that a decision‑maker, applying the VEA/MRCA claim provisions referenced in s 5, can lawfully find that MO or death from MO is connected with relevant service on the balance of probabilities (s 8). The instrument itself specifies the necessary elements; the following are practical steps derived from its wording and structure.

1. Confirm the diagnosis matches the statutory definition. Use clinical records and expert evidence to demonstrate that the person’s condition meets the definition in s 7(2): a genetic disorder of bone growth with multiple benign cartilage‑capped bone tumours (osteochondromas or exostoses) that grow outward from the metaphyses of long bones. Explicitly exclude synovial osteochondromatosis and enchondromatosis where present (s 7(2)(b)). Do not assume that ICD‑10‑AM coding alone establishes compliance: s 7(3) states the statutory meaning is that in s 7(2), even though the ICD code is noted (s 7(4)).

2. For death claims, show contribution to a terminal event. If the claim concerns death, compile medical records, death certificate material, and expert forensic opinion establishing that MO contributed to the terminal event or condition (s 7(5)). The Dictionary (Schedule 1) lists typical terminal events; map clinical evidence to those or equivalent terminal events to demonstrate causal contribution.

3. Establish the factor in s 9(1). The only factor listed is "inability to obtain appropriate clinical management for multiple osteochondromatosis" (s 9(1)). Therefore, assemble contemporaneous evidence that shows the claimant was unable to obtain clinical management that was appropriate for MO. The instrument does not define "appropriate" or the nature of the "inability", so evidence should address:

• What management was clinically indicated for the claimant's condition, as indicated in expert opinion.

• Efforts made by the claimant to secure that management (referrals, appointments, attempted admissions, correspondence, waitlist evidence).

• Reasons for the inability: for example, systemic unavailability, geographic access, administrative denial, denial of care related to service status, or other causes. Because s 10(1) requires the existence of the factor to be related to relevant service, the evidence must also tie the inability to obtain management to some aspect of the person's relevant service.

4. Tie the factor to relevant service. The Statement requires that any factor in s 9 be related to relevant service (s 10(1)). Use service records, postings, medical evacuation records, personnel files, and contemporaneous military health records to show the causal and temporal link between the person’s relevant service and the inability to obtain appropriate clinical management. Because s 10(2) confines the factor to MO suffered or contracted before or during (but not arising out of) relevant service, also gather evidence to establish the timing of onset of MO relative to service.

5. Address the "did not arise out of" limitation. If the claimant’s MO could be said to have arisen out of service, the s 9(1) factor is inapplicable (s 10(2)). For compliance under this Statement, ensure evidence supports that MO was either pre‑existing or contracted during service but not causally attributable to service activities. Where that is not the case, seek other Statements or statutory pathways; s 11 indicates that where a factor refers to another injury/disease covered by another Statement, that Statement’s factors apply.

6. Prepare expert opinion carefully. Medical experts should be asked to opine expressly against the statutory definitions and factors:

• Confirm whether the clinical picture satisfies s 7(2)'s definition.

• Address whether the claimant experienced an inability to obtain appropriate clinical management, what "appropriate" means in the clinical context, and whether that inability flowed from or was related to the claimant's relevant service (ss 9-10).

• For death cases, give explicit opinion on whether MO materially contributed to the terminal event indicated on death records (s 7(5)).

7. Check for related Statements. If the factual circumstances involve other injuries or diseases that are the subject of other Statements of Principles, identify those Statements and apply them in tandem as s 11 requires. Be alert to cross‑application that could alter the evidentiary requirements.

8. Map evidence to the balance‑of‑probabilities standard. Section 8 frames the Authority’s view in terms of "more probable than not." Evidence packages should therefore be organised to demonstrate that, on balance, the specified factor(s) existed and were related to relevant service. This ordinarily means affirmative evidence rather than bare assertions: contemporaneous medical records, service documentation, communications evidencing attempts to access care, and robust expert testimony.

9. Anticipate definitions and exclusions. Ensure that coding, diagnoses, or mixed pathology are reconciled with the instrument’s exclusions (s 7(2)(b)) and the textual definition. Where records use different nomenclature, obtain clarifying expert statements mapping the clinical terminology to the statutory definition.

10. Consider administrative timing. The instrument commenced on 23 May 2023 and repealed the 2015 Statement for MO (ss 2-4). For claims that straddle the repeal date, seek administrative guidance on which Statement applies to the particular claim. In the absence of transitional wording in the Statement, good practice is to record the date of the claim and the relevant decision timeframe and to prepare evidence that would satisfy either Statement where practicable.

Following the Statement’s text conservatively will position a claim for acceptance under the VEA/MRCA processes: establish the statutory diagnosis, document the inability to obtain appropriate clinical management, link that inability to the relevant service as defined in Schedule 1, and address timing relative to service so that the s 10(2) limitation is clearly met or deliberately excluded from reliance.