Statement of Principles concerning osteogenesis imperfecta (Reasonable Hypothesis) (No. 53 of 2023)

The SoP centres on a small set of tightly defined concepts. Those concepts determine the condition covered, the legal threshold for linking the condition to service, and the boundaries of application.

• Osteogenesis imperfecta (OI). The instrument adopts a clinical definition for OI: a group of genetic disorders of bone formation that typically involve low bone mass, bone fragility and an increased propensity to fracture (s 7(2)). Although the ICD‑10‑AM code Q78.0 is noted (s 7(3)-(4)), the SoP instructs that the textual definition in s 7(2) is the operative meaning for claims purposes.
• Death from OI. The SoP treats “death from osteogenesis imperfecta” as including a terminal event or condition that was contributed to by the person’s OI (s 7(5)). The Schedule defines “terminal event” concretely to include pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function (Schedule 1).
• Reasonable hypothesis threshold. The instrument is framed around the statutory “reasonable hypothesis” standard. It specifies that at least one enumerated factor must exist, as a minimum, before a reasonable hypothesis can be said to be raised connecting OI or death from OI with circumstances of relevant service (s 9). The SoP supplies only one such factor: inability to obtain appropriate clinical management for OI (s 9(1)).
• Relationship to relevant service. The SoP requires that any factor relied upon be related to the person’s relevant service (s 10(1)). It further confines the application of the single factor in s 9(1) to cases where the person’s OI was suffered or contracted before or during, but did not arise out of, the relevant service (s 10(2)). The Schedule defines “relevant service” expansively to include operational, peacekeeping, hazardous and British nuclear test defence service under the VEA, and warlike and non‑warlike service under the MRCA (Schedule 1).
• Interaction with other SoPs. Where a factor in s 9 refers to an injury or disease that is covered by another SoP made under s 196B(2) of the VEA, the SoP for that injury or disease applies according to its terms as in force (s 11).

Practically, these concepts create a concise legal framework: a claimant must show that the named factor exists and that it is related to relevant service as defined in the Schedule. The instrument anchors the medical meaning of OI for decision‑making, but delegates assessment of whether the specified factor existed and whether it is related to relevant service to the claims process under the VEA and MRCA.

The instrument affects a defined population of claimants, medical advisors and decision‑makers within the veterans’ entitlements and military rehabilitation compensation systems.

• Affected claimants. By the instrument’s application clause, it applies to any claim to which s 120A of the VEA or s 338 of the MRCA applies (s 5). The Schedule’s definition of “relevant service” identifies the covered categories of service: operational service, peacekeeping service, hazardous service, British nuclear test defence service under the VEA, and warlike or non‑warlike service under the MRCA (Schedule 1). Therefore, veterans and members of the Forces who rendered any of these types of service and who claim OI or death from OI fall within the instrument’s compass.
• Death beneficiaries and dependants. The SoP explicitly includes death from OI (s 7(1), (5)). For decedents whose terminal event was contributed to by their OI, the SoP’s factors and definitions will be applied when determining whether the death is connected to relevant service for the purposes of applicable claims provisions.
• Decision‑makers and medical assessors. The RMA’s SoPs are instruments designed to guide the tribunal/decision‑maker and medical advisers when applying the statutory “reasonable hypothesis” threshold. The RMA states there is sound medical‑scientific evidence supporting a relationship between OI and relevant service (s 8); decision‑makers will rely on that statement and on the single enumerated factor in s 9 when assessing causation under s 120A VEA or s 338 MRCA.
• Medical practitioners and record‑keepers. Because the sole factor that raises a reasonable hypothesis is inability to obtain appropriate clinical management (s 9(1)), treating clinicians, military medical services, and civilian providers whose records speak to access, referral, wait times, treatment refusals, or capacity to provide “appropriate clinical management” are potential sources of evidence used in claims. The Schedule’s inclusion of terminal events such as pneumonia and respiratory failure (Schedule 1) also implicates clinicians who certify causes of death.
• Administrators and policy staff. The RMA, Departmental decision branches, and appeals bodies must apply this SoP in the context of existing VEA and MRCA processes. The instrument also repeals the earlier 2015 SoP for OI (s 4), which means administrators must transition to the No. 53 of 2023 criteria for new and review claims.

Who does not fall within the instrument: persons whose claims do not invoke s 120A VEA or s 338 MRCA, or whose service does not fall within the Schedule’s definition of relevant service, are outside the SoP’s application. The instrument contains no provisions that directly regulate non‑veteran medical practice, private insurers, or general civil litigation.

This SoP does not create new civil liabilities, criminal offences, or regulatory fees. Instead, it defines the evidentiary and causal framework the Repatriation Medical Authority intends to apply for the “reasonable hypothesis” test in the specified claims processes. The principal operative duties and rights are therefore administrative and evidentiary.

• Duty to satisfy the reasonable hypothesis threshold. For a decision‑maker to find that a reasonable hypothesis exists connecting OI or death from OI with relevant service, at least one factor listed in s 9 must exist (s 9). The single factor provided is “inability to obtain appropriate clinical management for osteogenesis imperfecta” (s 9(1)). This is the minimum evidentiary requirement the SoP imposes for causation under the RMA framework.
• Duty to show relationship to relevant service. Any factor relied on must be related to the claimant’s relevant service (s 10(1)). The decision‑maker must therefore consider causation temporally and causally: the existence of the factor must have a nexus with the circumstances of relevant service as defined in the Schedule.
• Limitation on the factor’s application. The application of the factor in s 9(1) is explicitly limited to material contribution or aggravation where the person’s OI was suffered or contracted before or during (but did not arise out of) relevant service (s 10(2)). That means the factor is not intended by the RMA to substantiate claims where OI first arose as a consequence of service (the instrument’s language is that it applies where OI was suffered or contracted before or during, but did not arise out of, service).
• Right to have other SoPs incorporated where relevant. If a factor in this SoP refers to an injury or disease covered by another SoP determined under s 196B(2) of the VEA, then the factors in that other SoP apply according to their terms (s 11). This creates a right for decision‑makers and claimants to rely on the content of other SoPs where applicable.
• Right to rely on the RMA’s stated medical finding. Section 8 records the RMA’s view that sound medical‑scientific evidence indicates that OI and death from OI can be related to relevant service. While framed as the RMA’s view, in practice this statement is what decision‑makers and claimants will use to inform medical causation assessments when applying the statutory reasonable hypothesis standard.

The instrument does not create an enforceable private right of action, statutory compensation entitlement or monetary award by itself. Its role is evidentiary: it defines what the RMA considers sufficient to meet the reasonable hypothesis threshold in the context of statutory claims processes under the VEA and MRCA. The SoP shifts the administrative burdens: claimants must adduce evidence that the enumerated factor existed and that the factor was related to relevant service as defined in the Schedule.

The Statement of Principles contains no penalty provisions and does not establish direct enforcement mechanisms. It is an administrative instrument that specifies medical causation criteria to be used in statutory claims processes. The instrument’s enforcement consequences are therefore indirect and arise through the existing administrative and legal structures for veterans’ entitlements, not from the SoP itself.

• No offences or fines. The SoP does not create offences, sanctions, or civil penalties; no monetary fines, criminal penalties, or licensing sanctions are contained in the text.
• Administrative effect on claims. The practical enforcement effect of the SoP is that decision‑makers under the VEA and MRCA will apply the SoP’s factors when deciding whether a reasonable hypothesis exists for causation. Success or failure of claims will be affected by whether the claimant can show the s 9 factor and its relationship to relevant service as required by s 10. In that sense the SoP influences entitlement outcomes, but it does not prosecute or penalise conduct directly.
• Repeal and transitional effect. The instrument repeals the earlier SoP No. 35 of 2015 (s 4). That repeal changes the operative criteria for ongoing and future claims assessed under the RMA’s SoP framework; the enforcement consequence is administrative: decisions made after commencement should apply the No. 53 of 2023 criteria.
• Decision‑making bodies. Enforcement, meaning the grant or refusal of benefits, remains the responsibility of the statutory decision‑makers under the VEA and MRCA. The SoP is a determinative instrument the RMA provides to those bodies. The SoP itself contains no procedure for audit, compliance monitoring or review; those mechanisms remain in the primary legislation and administrative processes of the VEA and MRCA.

In short, the SoP’s practical force is to shape the evidentiary standard applied by decision‑makers. Any “penalty” is the potential denial of a claim when the required factor or the relationship to relevant service is not established. The instrument does not prescribe penalties for non‑compliance by third parties such as treating practitioners or institutions whose clinical management practices may be relevant to a claimant’s ability to obtain “appropriate clinical management”.

This SoP is an instrument made under the Veterans' Entitlements Act 1986 (s 3) and is expressly intended to operate within the decision frameworks of the VEA and the Military Rehabilitation and Compensation Act 2004 (MRCA).

• Primary legislation integration. The instrument’s stated application is to claims to which s 120A of the VEA or s 338 of the MRCA applies (s 5). Those sections are outside the text of this instrument, but the SoP is designed to be used within the causal assessment steps that those provisions trigger. The SoP’s legal effect is therefore dependent on the operation of those primary statutes and the relevant decision‑making processes they establish.
• Repeal of prior RMA instrument. The SoP repeals the previous Statement of Principles concerning osteogenesis imperfecta No. 35 of 2015 (s 4). Decision‑makers will substitute No. 53 of 2023 for No. 35 of 2015 when applying RMA criteria to new claims and, where applicable, reviews or appeals. The repeal may change the set of factors and the scope of application previously used in decisions.
• Relationship to other SoPs. Section 11 provides a cross‑instrument interaction mechanism: if a factor in this SoP refers to an injury or disease covered by another SoP made under s 196B(2) of the VEA, then the other SoP’s factors apply according to their terms as in force (s 11). That requires cross‑referencing multiple RMA instruments when a claimant’s presentation involves multiple diagnoses or linked conditions.
• Use of ICD‑10‑AM classification. The instrument refers to the ICD‑10‑AM code Q78.0 in relation to OI (s 7(3)-(4)). It specifies that a reference to an ICD‑10‑AM code is to the Tenth Edition effective 1 July 2017 edition, as published by the Independent Hospital Pricing Authority (s 7(4)). However, the instrument makes clear the textual definition in s 7(2) is the operative legal meaning for claims, so the ICD code serves as a cross‑reference rather than the controlling definition.
• Dependence on definitions in Schedule. The Schedule defines “relevant service”, “terminal event”, MRCA and VEA (Schedule 1). Those definitions determine which service types bring a person within the SoP and what is meant by terminal events contributing to death from OI.
• No express conflict‑resolution clause. The instrument does not contain express provisions dealing with conflicts between the SoP and other legislative provisions. Its placement under s 196B(2) of the VEA and its repeal of the prior SoP imply that it is the RMA’s current statement for causation assessments under the named statutory claim provisions; any legal tension with primary legislation would have to be resolved in the context of statutory interpretation and administrative practice under the VEA and MRCA.

Practically, decision‑makers, advisers and practitioners must read this SoP alongside the relevant primary legislation (s 120A VEA and s 338 MRCA), other RMA SoPs that may be engaged under s 11, and the RMA’s policies and procedures for claims processing. Where factors overlap with other conditions, the instrument requires the practitioner to apply the factors in the other SoPs as in force.

The instrument is self‑contained and records a concise amendment history limited to the current action taken by the Repatriation Medical Authority in April 2023.

• Current instrument. The Statement of Principles concerning osteogenesis imperfecta (Reasonable Hypothesis) (No. 53 of 2023) is dated 24 April 2023 and commences on 23 May 2023 (s 1; s 2).
• Repeal of previous SoP. The instrument expressly repeals the earlier Statement of Principles concerning osteogenesis imperfecta No. 35 of 2015 (Federal Register of Legislation No. F2014L01848) which was also made under subsection 196B(2) of the VEA (s 4). The repeal is unqualified in the instrument; the earlier instrument is no longer the operative RMA SoP for OI.
• No intervening amendments recorded. The instrument contains no other amendment notes, transitional provisions, or savings clauses. It therefore stands as a replacement of the earlier SoP without additional modification language in the instrument itself.
• Commencement timing. The instrument’s commencement date (23 May 2023) creates a temporal boundary: decisions on or after that date should apply the No. 53 of 2023 criteria. The instrument does not state whether decisions made prior to commencement should be revisited or how adjudicators should treat matters already the subject of final determinations; those matters fall to the administrative and appeal frameworks in the VEA and MRCA.
• No listed future amendments. The instrument contains no provisional amendments or sunset clauses. Any further changes to the SoP would require a separate RMA determination, presumably under the same statutory power (subsection 196B(2) of the VEA).

For practitioners, the immediate amendment history to note is the explicit repeal of the 2015 SoP and the effective commencement of the 2023 SoP on the stated date. The instrument does not itself record any litigation, appeals, or interpretative guidance emanating from the repeal or replacement process.

The instrument contains no litigation history or references to judicial decisions. It is a standalone administrative instrument determined by the Repatriation Medical Authority and makes no mention of court cases, tribunal determinations, or precedent.

• No cases named or cited. The text does not refer to any statutory interpretation cases, appellate decisions, or tribunal rulings that have considered the content or application of this SoP.
• No examples of disputes or appeals. The instrument does not record any prior contested decisions that led to the revision, nor does it include explanatory examples, tests or application notes that would indicate how courts or tribunals have interpreted the prior or current SoPs.
• Relevance for practitioners. Absence of litigation history in the instrument does not mean there will be no future litigation; it simply means the SoP itself supplies no jurisprudential context. Practitioners should be aware that application of the SoP’s single factor and the limits in s 10(2) may be the subject of administrative review and judicial scrutiny in future cases, but this instrument contains no adjudicative record to consult.

Because the instrument is silent on litigation, parties and advisers must rely on the text, the underlying VEA and MRCA processes, and any external case law interpreting the statutory “reasonable hypothesis” standard or the earlier 2015 SoP if relevant. The SoP itself neither records nor instructs on litigation outcomes.

This SoP is compact but contains several points where narrow wording or lacunae can trip up claimants, decision‑makers and advisers. These are matters of textual risk and practical implementation:

• Single‑factor threshold. The instrument provides only one factor (s 9(1)): “inability to obtain appropriate clinical management for osteogenesis imperfecta”. That means if a claimant cannot establish this factor, the RMA’s SoP framework, as written, provides no alternate path to raise a reasonable hypothesis connecting OI or death from OI to relevant service. Practitioners should note that the SoP’s narrow enumerated list limits admissible causation arguments within the RMA framework to that factor, unless other SoPs are implicated under s 11.
• Undefined key term: “appropriate clinical management”. The SoP does not define what counts as “appropriate clinical management”. The absence of a definition leaves decision‑makers to assess appropriateness contextually, drawing on medical evidence and the claimed facts. This creates evidentiary and interpretative uncertainty about what proof will suffice to show inability to obtain such management.
• Restrictive relationship to service in s 10(2). The factor in s 9(1) is expressly limited to cases where the person’s OI “was suffered or contracted before or during (but did not arise out of) the person’s relevant service” (s 10(2)). Practically, that excludes from this factor’s application cases where OI “arose out of” service , the instrument appears not to intend to use inability to obtain appropriate clinical management as the sole basis for attributing OI that first arose because of service. Practitioners must parse the claimant’s onset timeline carefully.
• Requirement that the factor be related to relevant service (s 10(1)). The mere existence of inability to obtain management is not enough; it must be related to the person’s relevant service. The Schedule defines relevant service by reference to particular categories (Schedule 1). Establishing the service nexus will require documentary and medical evidence linking access issues to service circumstances (for example, treatment unavailability during operational deployment), but the SoP doesn’t specify which types of evidence will suffice.
• Cross‑SoP dependencies. Section 11 requires application of other SoPs where a factor refers to an injury or disease already covered. That means some claims may require simultaneous analysis under multiple SoPs; decision‑makers must ensure they apply the other SoPs “as in force from time to time”, which introduces potential uncertainty if other SoPs are amended.
• Death causation scope. The SoP treats death from OI as including terminal events contributed to by OI (s 7(5)), and “terminal event” is defined narrowly in the Schedule (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function). Death causation arguments must therefore show that the listed terminal event was contributed to by OI; conditions outside the enumerated list will require careful framing within the “contributed to by” language.
• ICD‑10‑AM cross‑reference but not controlling. The instrument notes OI attracts ICD‑10‑AM code Q78.0 but explicitly states the operative meaning is s 7(2) (s 7(3)). Practitioners should not rely solely on ICD coding as determinative; the textual definition governs.
• Repeal transition. The instrument repeals the 2015 SoP (s 4) without transitional wording. Where prior decisions relied on No. 35 of 2015, there may be questions about retrospective application, but the SoP itself does not provide transitional guidance.
• No procedural detail. The SoP states medical causation criteria but provides no procedural guidance on evidence thresholds, expert report formats, or the way decision‑makers should approach ambiguous medical records. Claimants and advisers must therefore ensure they present targeted evidence addressing the specific factor and the service linkage.

These “gotchas” are textual and evidentiary. They identify where the instrument’s brevity creates issues for proof and interpretation, and where additional care in claim preparation and adjudication will be required.

Compliance in this context means preparing a claim for OI or death from OI so that a decision‑maker applying this SoP can properly conclude that a reasonable hypothesis exists connecting the condition to relevant service. Because the SoP contains a single enumerated factor and requires a service relationship, practical compliance involves assembling targeted evidence on both elements.

1. Demonstrate that the condition meets the SoP’s medical meaning

   • Establish that the person’s condition falls within the RMA’s textual definition of osteogenesis imperfecta (s 7(2)): a group of genetic disorders of bone formation involving low bone mass, bone fragility and an increased propensity to fracture. Medical records, genetic testing results, specialists’ notes and imaging may be used to show the diagnosis aligns with the definition. While the SoP references ICD‑10‑AM Q78.0, the textual definition is primary (s 7(3)-(4)).

2. Prove the existence of the enumerated factor

   • The claimant must show that “inability to obtain appropriate clinical management for osteogenesis imperfecta” existed (s 9(1)). Since “appropriate clinical management” is not defined, evidence that speaks to access to care, availability of specialist services, denial of treatment, prolonged wait times, lack of referral pathways, or absence of facilities during deployment may be relevant. Practical evidentiary sources include:
     • Military medical records and serving unit medical logs showing unavailability of required treatment or referrals during the relevant service period.
     • Civilian hospital and specialist records demonstrating attempts to obtain care and reasons for non‑provision (e.g. geographic remoteness, lack of specialist services).
     • Correspondence, policy documents or administrative records indicating limits in service medical capability at the time.
     • Sworn statements or affidavits from treating clinicians describing the clinical management required for the claimant and the reasons it could not be obtained.
   • Present the evidence so it addresses both inability to obtain care and why that care would be considered “appropriate” for OI management, by reference to accepted clinical standards where possible.

3. Establish the relationship to relevant service

   • The factor must be related to the person’s relevant service (s 10(1)). The claimant should map the temporal and causal link between the inability to obtain management and the relevant service event or period. For example:
     • Show that the inability to obtain care occurred during deployment, training or other listed relevant service (see Schedule 1 for the categories of relevant service).
     • Where the OI was present before service, show how service conditions materially contributed to or aggravated the condition through lack of access to appropriate management (s 10(2)).
   • Provide documentation tying the period of denied or unavailable care to the period and circumstances of relevant service, such as deployment orders, unit location logs, or evidence of service‑related transfer or evacuation that affected access.

4. Address death‑related claims

   • For claims of death from OI, show that a terminal event listed in the Schedule (for example pneumonia, respiratory failure) was contributed to by the decedent’s OI (s 7(5); Schedule 1). Death certificates, autopsy reports, treating clinicians’ statements and hospital notes should be compiled to demonstrate the contribution of OI to the terminal event.

5. Consider interaction with other SoPs

   • Where any factor in this SoP refers to an injury or disease covered by another RMA SoP, ensure that you obtain and apply the factors from that other SoP as in force (s 11). This will require checking the current RMA SoPs for related conditions and addressing any additional factor requirements.

6. Anticipate and address the textual constraints

   • Because the instrument provides no definition of “appropriate clinical management”, provide expert medical evidence that identifies what would have constituted appropriate management for the claimant’s OI and why it was not obtainable. Use contemporaneous records to corroborate subjective statements.
   • Where the claimant’s OI first arose during service, check whether the circumstance falls within the “did not arise out of” caveat in s 10(2); if the claim implicates OI that arose because of service, the single factor here may not be the appropriate basis and other legal pathways or SoPs may need to be considered.

7. Prepare persuasive presentation for administrative decision‑makers

   • Structure claim submissions to mirror the SoP: (a) establish the diagnosis under s 7(2); (b) prove the s 9(1) factor; (c) prove the s 10(1) nexus to relevant service; and (d) apply any other SoPs invoked under s 11. Present expert reports that expressly opine on whether the inability to obtain appropriate management materially contributed to or aggravated the claimant’s OI or, for a death claim, materially contributed to the terminal event.

8. Record retention and contemporaneous evidence

   • Keep complete service and medical records, and where practicable obtain contemporaneous statements from treating officers and clinicians. Given the evidentiary centrality of access to appropriate management, contemporaneous documentation of attempts to obtain care and responses is likely to carry significant weight.

The SoP supplies a focused evidentiary target. Compliance requires concentrated proof on the existence of the inability to obtain appropriate management and a clear causal link to the relevant service categories as defined in the Schedule. Where ambiguity remains about the sufficiency of evidence, advisers should ensure expert medical statements construct the necessary causal narrative aligned with the SoP’s text.