Statement of Principles concerning non-Hodgkin lymphoma (Balance of Probabilities) (No. 91 of 2018)

This instrument is a Statement of Principles concerning non-Hodgkin lymphoma (NHL) made by the Repatriation Medical Authority under subsection 196B(3) of the Veterans' Entitlements Act 1986, and compiled as No. 91 of 2018 with an amendment (No. 76 of 2021) incorporated as at 21 June 2021 (front matter, Dated 26 October 2018; compilation notes; Endnote 3). Its mechanical function is to set out the medical and exposure factors that, if established on the balance of probabilities, are sufficient to link a person’s NHL or death from NHL to their relevant service for the purposes of claims that fall under section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004, see section 5.

Mechanically, the Statement does three things. First, it defines the disease scope by specifying what is meant by non-Hodgkin lymphoma and what is excluded, see subsection 7(2) and (3). Second, it lists, in a single place, the “factors that must exist” , a finite catalogue of infections, clinical conditions, exposures, device presence and duration thresholds that the Repatriation Medical Authority regards as sufficient on the balance of probabilities to establish a connection between NHL and relevant service, see section 9. Third, it imposes a linking requirement: any factor relied on must be related to the person’s relevant service as defined in the Schedule, see section 10(1). There is a limited, specific qualification to how the inability to obtain appropriate clinical management factor may be applied, see section 10(2).

The legal standard invoked is the ordinary civil standard, balance of probabilities, reflected in section 8 where the RMA states its view that “it is more probable than not” that NHL and death from NHL can be related to relevant service. The Statement is operative as an instrument to be applied to claims that fall under the two statutory provisions named in section 5. It does not itself create an entitlement, prescribe benefit levels, or create offences; it is an evidentiary or determinative instrument to be used within the VEA/MRCA claims framework.

The Schedule to the instrument supplies precise definitions used throughout, including BMI and the BMI formula, a specified list of autoimmune diseases and systemic immunosuppressive drugs, definitions of chronic inflammation as specified, definitions of lindane and specified Borrelia species, Richter syndrome, terminal event and the statutory abbreviations MRCA and VEA. The endnotes record the instrument’s registration and amendment history, including the 2021 amendment that altered subsection 9(9) (Endnote 3 and Endnote 4).

The instrument rests on three linked legal-medical concepts: the disease definition, the closed list of qualifying factors and temporal/dose thresholds, and the requirement that the qualifying factor be related to relevant service.

Disease definition. Subsection 7(1) and (2) defines the scope of the instrument. Non‑Hodgkin lymphoma is described as a heterogeneous group of malignant lymphoproliferative diseases originating from T and B lymphocytes, presenting as solid tumours of the immune system that lack Reed‑Sternberg cells, and expressly includes several named subtypes, for example Burkitt lymphoma and mycosis fungoides. The Schedule further cross‑references to subsection 7(2) for the defined term non‑Hodgkin lymphoma. The instrument expressly excludes specific haematological disorders, including myeloma, hairy cell leukaemia, Waldenström macroglobulinaemia, acute lymphoblastic leukaemia and chronic lymphocytic leukaemia/small lymphocytic lymphoma, so the Statement’s factors do not operate to link those conditions to service under this instrument, see subsection 7(2)(c).

Closed list of qualifying factors. Section 9 sets out a discrete list of factors, any one of which, if present and related to relevant service, is sufficient on the balance of probabilities to link NHL or death from NHL to service. The list mixes infectious agents, prior disease states, clinical procedures, autoimmune conditions, pharmaceutical exposure, device presence and occupational/chemical exposure, with condition‑ and subtype‑specific limitations. Examples: HIV infection at the time of clinical onset (s9(1)); organ or bone marrow transplantation before onset (s9(2)); a specified list of autoimmune diseases diagnosed before onset (s9(3)); exposure to specified systemic immunosuppressive drugs for a continuous period of at least three months before onset, with a ten year post‑cessation window (s9(5)); infection with Epstein‑Barr virus before clinical onset (s9(9)); and specified occupational or environmental exposures with cumulative duration requirements, for example lindane for a cumulative period of at least one year on more days than not, with the first exposure at least five years before clinical onset (s9(21)), and pentachlorophenol for at least 2,000 hours within a consecutive ten year period, with first exposure at least five years before onset (s9(22)). Several factors are restricted to specific NHL subtypes, for example gastric lymphoma and Helicobacter pylori (s9(8)), Burkitt lymphoma and Plasmodium falciparum (s9(16)), and anaplastic large cell lymphoma of the breast and breast implants (s9(20)).

Temporal and threshold rules. Many factors contain temporal conditions or duration thresholds. The Schedule defines “being obese” as BMI 30 or greater, and subsection 9(18) requires obesity for at least ten years within the 20 years before clinical onset to qualify. Chronic inflammation as specified must be present for at least ten years before onset for diffuse large B‑cell lymphoma (s9(19)), with examples in the Schedule that include pyothorax from artificial pneumothorax, chronic osteomyelitis and metallic implant insertion. Drug exposure must be continuous and for a minimum duration, and where exposure ceases the Statement in s9(5) requires onset within ten years of cessation.

Primary claimants. The immediate population affected are persons lodging claims to which section 120B of the VEA or section 339 of the MRCA applies, see section 5. Those provisions themselves sit in statutory compensation and rehabilitation schemes; this Statement operates as the RMA’s determination of which medical factors, when proved and linked to relevant service, satisfy the balance of probabilities standard for service connection of NHL or death from NHL under those statutory claim mechanisms.

Decision‑makers and medical assessors. The Repatriation Medical Authority (RMA) is the authorising body, see section 3, and the Statement is intended to be applied by the decision‑making bodies that administer claims under the VEA and MRCA. While the instrument itself does not say how decision makers must apply it step by step, the instrument’s structure makes it central to the question whether a claimant’s NHL is considered connected to service. Medical practitioners preparing clinical evidence will be affected because their contemporaneous records, diagnostic tests, infection serology, surgical records and medication histories will be the material relied upon to establish the presence and timing of the factors specified in section 9 and in the Schedule definitions.

Veterans and former members of the Forces. Veterans and ex‑members whose service falls under the statutory categories listed in the Schedule’s definition of relevant service , eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service) under the VEA, or peacetime service under the MRCA , are within the instrument’s ambit if they lodge claims under the relevant statutory sections, see Schedule definitions and section 5. Families of deceased veterans may also be affected where death from NHL is claimed, given subsection 7(3) includes death from a terminal event or condition that was contributed to by the person’s NHL.

Private health providers and record keepers. Clinicians, hospitals and pathology services will be materially affected in practice because the Statement sets precise evidentiary thresholds. For example, proving infection by certain organisms at the time of clinical onset, demonstrating dates and duration of immunosuppressive drug exposure, documenting BMI history for obesity duration, or proving cumulative occupational exposure to lindane or pentachlorophenol will require documentary evidence that private providers hold or generate.

Insurers and third parties. While the instrument is made under veterans’ legislation, private insurers or employers may find consequences where their insureds or former employees are veterans making claims; their exposure to retrospective information requests or litigation could follow from the administrative decision that relies on medical evidence shaped by this Statement, although the instrument itself does not directly alter private insurance obligations.

Statutory origin and duty to determine. The Repatriation Medical Authority has the authority to determine Statements of Principles under subsection 196B(3) of the VEA, and this instrument records such a determination, see section 3. The RMA’s duty in making this Statement is implemented as a determination of factors on sound medical‑scientific evidence, see section 8; the instrument records the RMA’s view about causation on the balance of probabilities.

Claimant duty to establish factors and relationship to service. The Statement makes clear that, before NHL or death from NHL can be said to be connected with the circumstances of a person’s relevant service on the balance of probabilities, at least one of the factors in section 9 must exist, see section 9. Further, section 10(1) requires that the existence of the relevant factor must be related to the person’s relevant service. Practically, therefore, a claimant bears the evidentiary task of proving both the factor and its relationship to their relevant service; the instrument defines what proof is necessary in type and timing terms for many factors, for example timing rules in subsections 9(5), 9(18), 9(19), 9(21) and 9(22).

Rights afforded by implication. The instrument’s operation confers the right to have a claim assessed by reference to the RMA’s list of factors where the statutory claim provisions apply, see section 5. If a claimant can establish one of the factors in section 9 and also show that the factor is related to relevant service, then, on the balance of probabilities, the RMA’s instrument supports a finding of service connection for NHL or death from NHL. The instrument also gives claimants a predictable framework for what evidence to produce , this can be read as an implied procedural right to have medical evidence evaluated against the published factors and Schedule definitions.

Interaction right/duty with other Statements. Section 11 creates a duty on decision makers to consult other Statements where a factor in this Statement refers to an injury or disease covered by another Statement of Principles. The provision states that in such cases the factors in that other Statement apply “in accordance with the terms of that Statement of Principles as in force from time to time”, which creates a duty to apply the current terms of the other instrument.

No penal duties in instrument. The Statement itself does not set out penalties, sanctions, or criminal liabilities for non‑compliance; it is an evidentiary instrument used within statutory claims processes. The instrument’s role is administrative and determinative rather than disciplinary.

No criminal or civil penalties set out in the instrument. The Statement is an administrative, evidentiary determination made under subsection 196B(3) of the VEA; it does not itself create offences, fines, or civil penalties. There are no provisions in the instrument that prescribe enforcement mechanisms, monetary sanctions or offences for non‑compliance; the instrument is designed to guide claims assessment rather than to enforce conduct directly. This status is evident from its content: it defines disease scope, qualifying factors and relationships to service, but it contains no enforcement clauses.

Administrative enforcement and consequences. The practical “enforcement” of the Statement will be administrative in the context of the VEA and MRCA claims processes. That is, decision makers who administer claims under section 120B of the VEA or section 339 of the MRCA will apply this Statement in evaluating whether NHL or death from NHL is connected to relevant service. The consequence of applying the Statement will be acceptance or rejection of service connection for the purposes of those statutory claims. The instrument thus has binding operational effect within the statutory scheme it serves, in that meeting its elements will be material to entitlement determinations, although the instrument does not itself spell out entitlement outcomes or monetary awards.

Evidential consequences. Because the instrument sets out a closed list of factors and precise thresholds, a decision maker may treat a finding that at least one factor is established and related to service as determinative of service connection on the balance of probabilities. Conversely, absent any of the listed factors established and related to service, claimants may have difficulty establishing a service connection solely by reference to this Statement. The instrument therefore operates as an evidentiary sieve; however, it does not itself state procedural remedies or appeal routes.

Interaction with other Statements. Section 11 requires application of factors in other Statements where one of this instrument’s factors refers to another disease with a Statement of Principles. This creates an enforcement pathway in the sense that decision makers must assess cross‑referenced factors in accordance with the other Statement’s terms. The instrument does not, however, provide enforcement sanctions for failing to apply those other Statements; enforcement remains administrative and subject to statutory appeal rights under the VEA/MRCA frameworks, which are outside this instrument.

Recordkeeping and proof risks. The instrument’s numerous temporal and cumulative thresholds create enforcement‑adjacent risks; for example, inability to demonstrate the required exposure hours for pentachlorophenol (2,000 hours within a consecutive ten year period) or inability to show obesity for at least ten years within the 20 years before clinical onset may lead to administrative rejection of a claim. Those practical consequences are an enforcement effect, in the sense that claim outcomes will follow from compliance with the evidentiary rules established by the Statement.

Statutory nexus to the VEA and MRCA. The instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986, see section 3. Section 5 states that the instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies. Those cross‑references embed the Statement within the statutory compensation and rehabilitation frameworks; the Statement is therefore an instrument that informs how service connection is established under those provisions.

Cross‑Statement application. Section 11 provides an explicit mechanism for interaction between Statements of Principles: if a factor in this Statement refers to an injury or disease that has its own Statement under subsection 196B(3) of the VEA, then the factors in that other Statement apply according to its terms as in force from time to time. Practically, this means assessors must consult and apply the relevant other Statement(s) when, for example, a factor refers to a prior disease that is itself the subject of a separate Statement. The provision creates a layered application model across Statements.

Definitions that tie into statutory categories. The Schedule defines “relevant service” by reference to categories under the VEA and MRCA: eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service) under the VEA, or peacetime service under the MRCA. Those definitions determine which service episodes may be treated as relevant when linking a factor from section 9 to service under section 10(1). Because the Schedule anchors “relevant service” to statutory categories, the Statement’s application will depend on statutory interpretations of those categories when they are in dispute, creating an intersection between the Statement and litigation or administrative determinations about service classification under the VEA and MRCA.

Amendment and commencement interactions. The compilation notes and endnotes record registration and commencement dates for the instrument and its amendment. The original Statement was registered 29 October 2018 and commenced 26 November 2018, and the Amendment Statement (No. 76 of 2021) was registered 24 May 2021 and commenced 21 June 2021, see Endnote 3. Decision makers must apply the version of the Statement in force at the relevant time, in line with the amendment history. Section 11’s cross‑Statement rule requires assessors to apply other Statements as “in force from time to time”, which emphasises the temporal interplay of instruments and amendments.

Compilation and amendment entries. The front matter records this document as Compilation No. 1, compilation date 21 June 2021, and it includes amendments up to Amendment Statement of Principles concerning non-Hodgkin lymphoma (Balance of Probabilities) (No. 76 of 2021) (F2021L00612); the day of commencement of that Amendment Statement is 21 June 2021 (front matter). Endnote 3,Legislation history records that the Statement of Principles concerning non‑Hodgkin lymphoma (No. 91 of 2018) was registered 29 October 2018 and commenced 26 November 2018, and that Amendment No. 76 of 2021 was registered 24 May 2021 and commenced 21 June 2021.

Provision‑level amendment note. Endnote 4,Amendment history indicates that subsection 9(9) was amended by No. 76 of 2021. The compilation text incorporates that amendment in force as at the compilation date. The endnotes also record that sections 2 and 4 (provision numbering in the instrument as previously published) were repealed by provisions of the Legislation Act; specifically the amendment history table notes “Section 2 … rep LA s 48D” and “Section 4 … rep LA s 48C”, see Endnote 4. The compilation reflects the current numbering after those repeals, as seen in the present text where sections proceed from 1 to 3 to 5 et cetera.

Practical effect of the s9(9) amendment. Subsection 9(9) as shown in the compiled text now reads “having infection with Epstein‑Barr virus before the clinical onset of non‑Hodgkin lymphoma”. The endnote records that this subsection was amended by No. 76 of 2021, which suggests the timing or scope of the EBV factor was altered by that amendment. Assessors and claimants must therefore be alert to the version under which a claim is made, and whether the EBV factor applicable to a particular claim was governed by the pre‑2021 wording or post‑amendment wording, depending on the claim’s relevant date and the applicable legislative or transitional rules set out for the amendment; the compilation notes however advise that any uncommenced amendments are not shown and that application, saving and transitional provisions are in the endnotes if relevant.

Compilation notes and uncommenced amendments. The compilation incorporates amendments in force up to 21 June 2021, and it includes a note that uncommenced amendments are not shown in the compiled text. The front matter directs readers to the Legislation Register for any uncommenced amendments and to the series page for information on modifications. Practitioners must therefore consult the register for the most current instrument and for any transitional or savings provisions that affect applicability of amendments.

Instrument contains no case law citations. The Statement of Principles itself does not cite, reference or record any judicial decisions. The instrument is a statutory administrative document and contains no litigation history within its text. The Schedule and sections make no reference to judicial interpretation, and the endnotes list only registration and amendment histories and not cases.

Implications for legal practice. The absence of litigation references in the instrument means that practitioners must look beyond the instrument to identify any case law that interprets Statements of Principles, or that addresses how decision makers apply them, including judicial review or merits review decisions under the VEA and MRCA frameworks. The instrument itself supplies the determinative medical factors and their definitions; case law, where it exists, would be external and must be located in reporters or decision databases rather than within the instrument.

No internal disputes or appeals recorded. There are no internal records in the instrument of disputes, appeals, or instances where this Statement has been judicially challenged. Any litigation arising from decisions that apply this Statement will therefore be external to the document and must be searched for in the usual legal databases. The instrument’s endnotes provide a registry trail for amendments, but not litigation.

Cross‑Statement litigation possibilities. Section 11’s cross‑reference to other Statements may generate litigation where there is disagreement over how factors in another Statement should be applied to a particular claimant; however, the present instrument records no such cases. Practitioners should be prepared to consult both this Statement and any other relevant Statements when assessing a claim, and to identify and prosecute any judicial review or merits review grounds in the applicable review forums.

No recorded judicial interpretations of defined terms. The Schedule supplies precise definitions for terms such as BMI, lindane and terminal event; the instrument itself contains no judicial glosses. Where disputes arise about, for example, the interpretation of “being obese for at least ten years within the 20 years before the clinical onset”, practitioners should expect to need supporting evidence and to be prepared to argue the construction in administrative or judicial review processes, but again the instrument itself contains no litigation history.

Timing and duration thresholds are strict and varied. Many factors in section 9 include precise temporal or duration requirements. Examples include: systemic immunosuppressive drugs must have been taken continuously for at least three months before clinical onset, and where exposure has ceased the onset must occur within ten years of cessation (s9(5)); obesity must have been present for at least ten years within the 20 years before clinical onset (s9(18)); chronic inflammation as specified must have been present at the affected site for at least ten years before onset for diffuse large B‑cell lymphoma (s9(19)); lindane exposure requires inhalation, ingestion or cutaneous contact on “more days than not” for a cumulative period of at least one year, with exposure commencing at least five years before onset (s9(21)); pentachlorophenol requires a cumulative period of at least 2,000 hours within a consecutive ten year period and the first exposure must have been at least five years before onset (s9(22)). Failure to document dates and cumulative durations precisely is likely to be fatal to a claim that relies on those factors.

Evidence of infection at a specific time. Several factors require infection “at the time of the clinical onset” of NHL, for example HIV (s9(1)), HTLV‑1 for adult T‑cell leukaemia‑lymphoma (s9(7)), Helicobacter pylori for gastric lymphoma (s9(8)), Campylobacter jejuni for small intestinal MALT lymphoma (s9(11)), Chlamydia psittaci for ocular adnexal MALT lymphoma (s9(12)), Borrelia species for cutaneous MALT lymphoma (s9(13)), Kaposi’s sarcoma herpesvirus for certain subtypes (s9(10)), and hepatitis B and C for B‑cell lymphoma and more generally (s9(14), s9(15)). Establishing infection status at the precise time of clinical onset will usually require contemporaneous laboratory or histopathology evidence; retrospective serology alone may not always be sufficient to show infection at the time of clinical onset unless medical records clearly document timing.

Differences between “before” and “at the time of” language. The Statement uses both “before the clinical onset” (for example EBV at s9(9)) and “at the time of the clinical onset” (for many infectious agents and certain clinical states). Those differences matter because “before” may allow a wider window of proof, while “at the time of” suggests contemporaneous evidence will be necessary to meet the factor. Practitioners must read the precise wording in each subsection carefully.

Requirement that factor be “related to” relevant service. Section 10(1) demands that any factor be related to relevant service. It is insufficient to show that a factor exists in a claimant’s clinical history; the claimant must also link how that factor arose from, or was otherwise related to, the relevant service as defined in the Schedule. For example, establishing exposure to pentachlorophenol or lindane will require linking workplace or service records to the person’s service history; demonstrating that an infection was acquired in service versus at another time will require medical and service records.

Establish the right statutory pathway. Begin by confirming that the claimant’s claim falls under the statutory provisions referenced in section 5, namely section 120B of the VEA or section 339 of the MRCA. The Statement applies only to claims to which those sections apply; if a claim lies outside those provisions, this Statement will not govern the evidentiary linkage required.

Identify which factor in section 9 is most readily provable. Section 9 contains a closed list; if at least one of those factors can be established and related to relevant service, the claimant will satisfy the Statement’s criterion on the balance of probabilities, subject to section 10(1). Routine triage of claim evidence against each subsection of section 9 will show which factor is the most straightforward to prove for the particular client.

Gather contemporaneous medical records and diagnostic evidence. For infectious‑agent‑based factors that require infection “at the time of the clinical onset”, collect histopathology reports, microbiology cultures, serological testing with dated results, oncological notes and the clinical onset date. For EBV where subsection 9(9) requires infection “before the clinical onset”, collect any pre‑onset serology or documented evidence of prior infection. For transplants, obtain surgical and transplant clinic records showing dates relative to clinical onset (s9(2)).

Assemble medication histories and exposure durations. For the systemic immunosuppressive drug factor (s9(5)), collate prescription records, dispensing records and clinical notes showing continuous use for at least three months before onset, and, if exposure ceased, document the cessation date and ensure the onset is within ten years. For pentachlorophenol and lindane, gather occupational exposure records, rosters, safety logs, material safety data sheets, operations reports and any other documentation that can establish cumulative hours or cumulative year‑long exposure “on more days than not”, together with timestamps showing first exposure at least five years before onset where required (s9(21), s9(22)).

Document BMI history and chronic condition durations. For obesity under subsection 9(18), compile weight and height records over time sufficient to demonstrate BMI 30 or greater for at least ten years within the 20 years before onset; use medical clinic notes, fitness or military medical records, and where appropriate corroborative records that document body weight across years. For chronic inflammation as specified in subsection 9(19), gather surgical, imaging, pathology and outpatient records that demonstrate chronic suppuration or inflammation at the affected site for at least ten years, noting the Schedule examples such as pyothorax from artificial pneumothorax, chronic osteomyelitis or implant‑related chronic inflammation.