Statement of Principles concerning osteonecrosis (Balance of Probabilities) (No. 14 of 2020)

The central legal-technical concept in the instrument is a Statement of Principles used to establish medical causation on the balance of probabilities for entitlements under specified provisions of the VEA and MRCA. The instrument identifies:

• The disease to which the Statement applies, namely osteonecrosis, defined as bone death due to loss of blood supply and inclusive of dysbaric osteonecrosis (s 6(2)). The instrument emphasises that ICD‑10‑AM codes are associated but the operative definition is the textual one in s 6(2) and the ICD‑10‑AM citation is a reference only (s 6(3)-(4)).

• Death from osteonecrosis, which is not restricted to immediate bone death but includes death from a terminal event or condition to which a person’s osteonecrosis contributed (s 6(5); Schedule 1 definition of “terminal event”).

• The evidentiary standard deployed: balance of probabilities. The RMA explicitly states it is “of the view that it is more probable than not” that osteonecrosis can be related to relevant service (s 7). That statement is the medical foundation for treating the listed factors as sufficient for causal connection when present and related to service.

• The factors in s 8. The instrument lists 25 enumerated factors, each of which functions as a pathway to establish that osteonecrosis or death from osteonecrosis can be related to relevant service if the factor is present and causally linked to service (s 8(1)-(25)). Some factors are generic (trauma, fracture, hypercoagulable states), some are exposure-based with defined thresholds (alcohol, smoking, specific drugs, glucocorticoid dosing), and some are disease or treatment states (solid organ malignancy, autoimmune disorders, haematological diseases, solid organ/stem cell transplant, chronic renal failure, dyslipidaemia, Cushing syndrome, HIV infection).

• Technical thresholds and definitions at Schedule 1. The Schedule operationalises the factors by setting exact thresholds or lists. Examples: “glucocorticoid therapy as specified” requires a cumulative dose equivalent to listed thresholds (Schedule 1 table and definition), “pack‑years” has a precise calculation in Schedule 1, “hyperbaric exposure as specified” lists pressure/time/depth combinations that qualify, and “hypercoagulable state as specified” lists conditions that qualify. Osteoclast inhibitors and antiangiogenic agents are defined and examples provided (Schedule 1).

• Relationship to service requirement. The presence of a listed factor alone is not sufficient; it must be related to the relevant service rendered by the person (s 9(1)). For the “inability to obtain appropriate clinical management” factor in s 8(25) there is a narrower operation: it applies only where osteonecrosis was suffered or contracted before or during (but did not arise out of) the person’s relevant service, and the inability materially contributed to, or aggravated, the condition (s 9(2); s 8(25)).

• Interaction with other Statements. If a factor in s 8 refers to an injury or disease for which another Statement of Principles exists, that other Statement applies according to its terms (s 10). The instrument therefore nests and defers to other RMA Statements where relevant.

These concepts have operational consequences. The instrument converts clinical questions,was the condition caused by service?,into inquiries about categorical thresholds and timing. For example, glucocorticoid exposure must meet equivalent cumulative dose and average rate thresholds in Schedule 1 if it is to be treated as a qualifying factor (Schedule 1 definitions). Alcohol consumption must be calculated using an Australian standard of 10 grams per standard drink when applying s 8(4) (note to s 8(4)). The instrument thus shifts much of the medical causation contest into documentary proof that the person’s exposures or comorbidities meet the specified thresholds and fall within the specified temporal windows relative to “clinical onset,” a term the Statement uses repeatedly but which is not defined in Schedule 1. Practitioners must therefore match clinical onset dates in medical records to the instrument’s time windows.

Finally, the Statement provides for precise subcategories such as osteonecrosis of the jaw, which has distinct qualifying factors (s 8(24) and Schedule 1 definitions of osteoclast inhibitor and antiangiogenic agent). That segmentation matters for claim preparation and evidence collection because the set of qualifying factors and required supporting documentation differ depending on the site and aetiology alleged.

This Statement of Principles affects multiple classes of actors within the veterans’ compensation system and adjacent professional spheres.

Primary affected persons

• Veterans and members of the Forces who lodge claims under section 120B of the VEA or section 339 of the MRCA. The instrument explicitly applies to claims “to which section 120B of the VEA or section 339 of the MRCA applies” (s 4). Those claimants must satisfy the causation criteria set out here if they rely on the RMA Statement to establish that osteonecrosis or death from osteonecrosis is connected to their relevant service.

• Deceased persons’ estates or dependants making death claims where osteonecrosis contributed to the terminal event. The Statement includes death from osteonecrosis and explains that death includes a terminal event or condition to which osteonecrosis contributed (s 6(5); Schedule 1 definition of “terminal event”).

Decision-makers and administrative actors

• The Repatriation Medical Authority is the instrument-maker and the source of the medical criteria (s 3; s 7). The RMA’s findings of what is “more probable than not” underpin application of the factors by other decision-makers.

• Decision-makers under the VEA and MRCA who adjudicate claims to which s 120B or s 339 apply. The instrument does not itself award benefits; it supplies the medical causation framework that those decision-makers will apply when assessing whether an entitlement is caused by relevant service. The instrument also interacts with other Statements of Principles through s 10, meaning decision-makers must consult multiple Statements where factors cross-refer.

Clinical and evidentiary actors

• Treating clinicians, specialists and medico-legal experts. The instrument requires clinical evidence matching specific thresholds, for example: laboratory values for dyslipidaemia, glomerular filtration rates or dialysis records for chronic renal failure, cumulative and average glucocorticoid dosing and dates for steroid exposure, and medication records for drugs such as bevacizumab or denosumab (s 8; Schedule 1). Clinicians preparing reports for claims must therefore provide quantification aligned with the Schedule 1 definitions.

• Dentists and oral/maxillofacial specialists in cases of osteonecrosis of the jaw. The Statement lists dental disease and treatment factors (s 8(24)(b), (f)-(g); Schedule 1) that will require dental records, treatment histories and specialist opinions.

Other indirectly affected parties

• Insurers, employers, and medical record custodians where medical histories are relevant to claims and to establishing exposure thresholds.

Geographic and service-scope limits

• The instrument attaches “relevant service” to particular service categories in Schedule 1: eligible war service (other than operational) under the VEA, defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA (Schedule 1 definition of “relevant service”). This matters for claimants whose service falls outside those categories; the Statement only operates for claims that fall under the statutory sections specified in s 4 and where the person’s service meets the Schedule 1 definition of relevant service.

Secondary effects on behaviour

• Claimant behaviour: The precise thresholds and temporal windows will influence what evidence claimants and advisers obtain and how they frame causation arguments. For example, smoking history should be quantified in pack‑years per Schedule 1, alcohol consumption recorded in grams per week as specified in s 8(4) and its note, and steroid dosing documented against the cumulative and average rate thresholds in Schedule 1.

• Clinician reporting: Specialists will need to tie clinical onset dates to exposures and to quantify exposures in the specific units used in the Statement.

In short, the Statement primarily affects claimants seeking to establish service‑connection for osteonecrosis and death from osteonecrosis, the administrative decision-makers who apply the VEA and MRCA entitlement rules, and clinicians who supply the quantifiable medical evidence the Statement requires.

This Statement of Principles primarily creates a framework of evidentiary duties rather than substantive rights or criminal offences. It derives its force from being the RMA’s established medical causation template under the VEA (s 3; s 7). The key duties and operative legal effects, as set out in the instrument, are:

Duty to establish qualifying factor(s)

• A claimant must establish the existence of at least one factor listed in s 8, and that the factor is related to the person’s relevant service, before it can be said on the balance of probabilities that osteonecrosis or death from osteonecrosis is related to relevant service (s 8; s 9(1)). The instrument therefore imposes the duty to prove presence of qualifying factors with the specified timing, dose or diagnostic thresholds.

Duty to link factor to relevant service

• Even if a factor in s 8 exists, s 9(1) requires that the factor “must be related to the relevant service rendered by the person.” The instrument does not set out the specific legal tests for when a factor is “related” to service; that legal question is decided within the VEA/MRCA claim process using the RMA’s medical parameters as input. Practically, claimants must adduce evidence that connects the identified factor to the person’s service period or occurrences during service.

Special duty for inability to obtain appropriate clinical management

• The factor in s 8(25) (inability to obtain appropriate clinical management) has a limited operation: under s 9(2) it only applies to material contribution to, or aggravation of, osteonecrosis where the person’s osteonecrosis was suffered or contracted before or during (but did not arise out of) relevant service. That imposes a causal and temporal duty distinct from other factors: the underlying osteonecrosis must predate or coincide with service and must not have arisen out of service.

Duty to rely on other Statements when cross-referenced

• If an s 8 factor refers to an injury or disease covered by another Statement of Principles, s 10 requires that the factors in that other Statement apply in accordance with its terms. This creates a duty on decision-makers and claimants to consult and comply with other applicable RMA Statements, not to treat the s 8 factor in isolation.

Evidentiary duties tied to Schedule 1 definitions

• The Schedule translates many factors into hard thresholds. For example, “glucocorticoid therapy as specified” requires cumulative and minimum average dose thresholds derived from a table of equivalent glucocorticoids in Schedule 1. “Pack-years” of smoking are defined numerically. “Hyperbaric exposure as specified” details exposure types and time/depth thresholds. These definitions impose duties to establish facts with specificity, not merely in general terms.

Rights and presumptions

• The Statement itself does not create a freestanding entitlement. Instead, it functions as the medical standard applied when decision-makers determine whether a condition is “related to service” under the VEA/MRCA provisions specified in s 4. A person lodging a claim to which s 120B VEA or s 339 MRCA applies has the right to have the RMA’s Statement applied to the medical causation question.

No penal rights or direct monetary obligations in the instrument

• The Statement contains no penalty regime, fines or criminal provisions; it is an administrative evidentiary instrument (see Penalties and enforcement below). Rights to benefits remain governed by the VEA and MRCA statutes and implementing administrative practice.

Practical duties for medical witnesses and practitioners

• Treating clinicians and expert witnesses who supply reports for claims must quantify exposures and diagnoses in the units and timeframes the Statement uses. Examples: record GFR and dialysis status to establish “chronic renal failure” as defined in Schedule 1, document laboratory lipid values to meet the dyslipidaemia thresholds, or quantify alcohol consumption in grams per week against the 320 grams threshold in s 8(4).

Allocation of decision power

• The RMA provides the medical standard; the decision-maker applying the VEA or MRCA retains the statutory decision-making power to accept or reject claims. The Statement operates as the RMA’s medical finding that, where a listed factor exists and is related to service, it is more probable than not that osteonecrosis can be related to service (s 7). The Statement therefore influences the administrative burden of proof and the structure of decisions, but does not itself determine entitlement outcomes; those remain for the relevant statutory decision-maker.

The Statement of Principles instrument contains no criminal or civil penalty provisions and does not itself provide an enforcement apparatus. Its legal effect is administrative and evidentiary. Key points drawn from the instrument:

No express penalties in the instrument

• The instrument does not create offences, sanctions or monetary penalties. It is a medical standard set under subsection 196B(3) of the VEA (s 3) and not a penal instrument. There are no enforcement provisions within the text that impose fines, imprisonment or administrative sanctions for non‑compliance with its terms.

Administrative enforcement through the statutory claims process

• The operational effect of the Statement is realised when decision‑makers under the VEA and MRCA apply it in the course of adjudicating claims to which s 120B of the VEA or s 339 of the MRCA apply (s 4). In practice, administrative “enforcement” consists of decision-makers accepting or rejecting claimed service-connection for osteonecrosis or death from osteonecrosis on the basis of whether the claimant has adduced sufficient evidence that one or more of the s 8 factors exists and is related to relevant service (s 8; s 9). The instrument supplies the causation yardstick; acceptance or rejection of claims is how the regime is enforced administratively.

Evidentiary weight and procedural effect

• Where the specified factor(s) in s 8 are proved and related to service, the RMA’s Statement supports a finding that it is more probable than not that osteonecrosis is related to service (s 7). Conversely, absence of any qualifying factor, or failure to link a factor to relevant service, provides a legitimate basis for rejection of service-connection claims. That is the practical enforcement mechanism: evidentiary sufficiency or insufficiency measured against the Statement.

No investigatory or compliance powers granted

• The Statement does not give the RMA investigatory powers or enforcement discretion. It provides definitions and thresholds; the exercise of investigatory functions, record-gathering, or administrative coercion (for example through subpoenas) would depend on the other statutes and administrative instruments that govern the claims process, not on the Statement itself.

Risk of proxy penalties via entitlement consequences

• Although the instrument imposes no direct fines, its definitional strictness can have powerful indirect consequences for claimants. If a claimant cannot provide evidence to meet the Schedule 1 thresholds or temporal windows in s 8, their claim for service-connection may be rejected under the VEA or MRCA entitlements framework. That administrative outcome can functionally deny access to benefits. The instrument therefore shifts the locus of “enforcement” to documentary and medical proof obligations that, if unmet, will result in non-acceptance of a claim.

Rights to challenge administrative decisions remain outside the instrument

• The Statement does not modify or comment on the appeal or review rights available under the VEA or MRCA. Those procedural and judicial review mechanisms exist in the parent statutes and are not altered by this instrument.

In short, enforcement of this Statement occurs within the administrative decision-making process for veterans’ entitlements. The Statement sets the medical thresholds; the consequences (acceptance or rejection of claims) follow under the VEA/MRCA procedures and the administrative regime that applies to those statutes.

This Statement operates as part of the statutory architecture governing veterans’ entitlements, and it explicitly cross‑references other statutory instruments and definitions. The instrument’s own text provides the primary pointers to legal interaction:

Source authority and parent statutes

• The Statement is made under subsection 196B(3) of the VEA (s 3). It applies to claims to which s 120B of the VEA or s 339 of the MRCA apply (s 4). Therefore, the Statement should be read and applied within the adjudicative and entitlement framework those sections establish. Any legal effects,acceptance or rejection of claims,are determined under the VEA and MRCA processes, not by the Statement alone.

Interaction with other Statements of Principles

• Section 10 provides a direct mechanism for interaction: if a factor in s 8 refers to an injury or disease covered by another Statement of Principles (an RMA Statement made under s 196B(3) of the VEA), then the factors in that other Statement apply according to their terms. Practically, this creates a hierarchy and cross-referencing regime where the present Statement defers to and incorporates other RMA Statements when particular factors invoke another disease entity. Decision-makers must therefore consult both Statements and apply the relevant one where cross-references occur.

ICD‑10‑AM references and external standards

• Section 6(3)-(4) states that while osteonecrosis attracts particular ICD‑10‑AM codes, the meaning of osteonecrosis for this instrument is the textual definition in s 6(2). The instrument also explicitly references the ICD‑10‑AM Tenth Edition, effective 1 July 2017, as published by the Independent Hospital Pricing Authority (s 6(4)). That means clinicians and decision-makers may use ICD coding as supportive evidence, but the statutory definition controls.

Definitions that adopt medical or clinical thresholds

• Schedule 1 imports medical thresholds and concepts that dovetail with other areas of healthcare regulation and clinical practice. For example, the definition of chronic renal failure uses glomerular filtration rate and dialysis/transplant criteria; dyslipidaemia is tied to laboratory lipid value thresholds. When adjudicating claims, decision-makers will rely upon clinical tests and medical records that are also governed by privacy, medical records, and health-care regulatory frameworks outside the VEA/MRCA ecosystem.

Temporal and service-type interaction

• The Schedule 1 definition of “relevant service” identifies specific categories of service under the VEA or MRCA to which the instrument applies. That interacts with the broader statutory definitions of “eligible war service,” “defence service,” “hazardous service,” and MRCA “peacetime service,” which are defined in the parent Acts. Whether a particular period of service constitutes “relevant service” for these purposes will depend on the definitions and exemptions contained in those Acts.

No conflict with criminal or tort law stated

• The Statement does not purport to displace or alter criminal liability, workers’ compensation, civil tort causes of action, or industrial compensation regimes. Nothing in the text asserts pre-emption of non‑statutory remedies. However, the Statement’s medical findings may be used in other legal contexts as clinical evidence, subject to evidentiary rules in those forums.

Administrative procedural law interaction

• Application of the Statement in claims will intersect with the administrative law procedures set out in the VEA/MRCA, including materiality, evidence admissibility, procedural fairness and review rights. Those procedural safeguards and paths of review are not described in the instrument but will be relevant when the Statement is applied in decision-making.

Interaction with pharmaceutical regulation and clinical practice

• The Schedule defines classes of drugs (osteoclast inhibitors, antiangiogenic agents) and names example drugs such as bevacizumab, denosumab and thalidomide. Those pharmaceutical classifications will interact with therapeutic use, prescribing records, and drug scheduling under the Therapeutic Goods and Medicines regulatory regime when determining whether exposure thresholds are met.

In summary, the Statement functions as a medical causation node in a network of statutory, clinical and administrative regimes. It must be applied in concert with the VEA and MRCA decision‑making frameworks and in conjunction with other RMA Statements and clinical standards identified in the Schedule.

The instrument itself records its own key dates and identifying details but includes no amendments or variation history within the text provided. Reported particulars in the instrument are:

• Instrument title and number: Statement of Principles concerning osteonecrosis (Balance of Probabilities) (No. 14 of 2020) (s 1 heading and title page).

• Date of the RMA determination: The instrument is dated 28 February 2020 (title page).

• Commencement: The instrument states that it commences on 23 March 2020 (s 2).

• Authority: Made under subsection 196B(3) of the Veterans' Entitlements Act 1986 (s 3).

The instrument does not list any subsequent amendments, revocations or prior versions within the text provided. It does, however, make cross-references to external materials whose editions are specified, which can be relevant to future amendment interactions:

• ICD‑10‑AM edition: The instrument cites the ICD‑10‑AM Tenth Edition, effective date 1 July 2017, as the edition used for the ICD code cross-reference (s 6(4)). If a later edition replaced the cited edition, practitioners must check whether the RMA has updated the Statement or whether decision-makers accept newer editions in practice.

• The Schedule sets out clinical and pharmacological examples and thresholds that may be subject to change by the RMA in future Statements. For instance, examples of antiangiogenic agents and osteoclast inhibitors are illustrative and the Schedule notes that lists are not exhaustive. Any subsequent RMA Statement or amendment could add or remove examples or revise thresholds.

No internal change-log or legislative instrument registration details are included in the text provided. The instrument does not state an expiry date; Statements of Principles typically remain in force until amended or replaced by the RMA under its statutory power. Practitioners should therefore verify the current status of this Statement with the RMA or the consolidated register of Statements of Principles to ensure no later amendment has altered thresholds, definitions or scope.

Because the instrument operates by reference to both the VEA and MRCA, any amendment to the procedural sections of those Acts that determine how Statements of Principles are used, or amendments to sections 120B (VEA) or 339 (MRCA), could affect the practical operation of the Statement without any change to the instrument itself. Those parent‑statute changes are beyond the instrument’s text but are relevant to its operational history.

The instrument does not record any litigation history, cases, or judicial interpretations within the text provided. No court decisions or tribunal rulings are cited or attached to the Statement. The instrument names no cases.

What the instrument does provide is the RMA’s medical view (s 7) and definitions; it does not purport to be a judicial determination. Legal challenges to the application of an RMA Statement typically occur within the context of administrative decisions under the VEA or MRCA, where affected parties may seek merits review or judicial review of a decision that relied upon a Statement. This instrument contains no report of such reviews.

Practical implications for practitioners:

• Absence of cited litigation in the instrument means the Statement should be treated as the RMA’s contemporaneous medical position as at its date. Any questions about how courts or tribunals have treated this particular Statement would need to be researched in the decisions databases for cases decided after the instrument’s commencement date (23 March 2020).

• If a claimant or decision-maker wishes to contest how the Statement has been applied in a particular claims decision, the relevant procedural pathways available under the VEA or MRCA and administrative law (merits review bodies, ombudsman, federal courts for judicial review) are the forums in which litigation or challenge would occur. The Statement itself does not provide guidance on remedies or appeal pathways.

Because the text supplied contains no litigation references, advisers should not assume judicial endorsement of the specific thresholds and lists in this instrument; rather, those thresholds are the RMA’s expert medical determinations to be applied administratively. Any jurisprudential weight or deference to this Statement in litigation would need to be established by reference to actual case law decided after the commencement date.

This instrument contains numerous technical details and narrow formulations that produce potential pitfalls for claimants, clinicians and advisers. Below are specific “gotchas” drawn directly from the text and Schedule, with practical consequences:

1. Clinical onset is used repeatedly but not defined

• Many factors require timing in relation to the “clinical onset of osteonecrosis” (for example, trauma or fracture within two years of clinical onset at ss 8(1)-(2)). The instrument does not define “clinical onset” in Schedule 1. That leaves contested issues about whether onset means first symptoms, first clinical diagnosis, first imaging evidence, or another marker. Practitioners should ensure medical records explicitly identify and justify a date of clinical onset to align with time windows in s 8.

2. Strict quantification of exposures and doses

• The Schedule defines “pack‑years” numerically and gives an equivalence to grams of tobacco (Schedule 1). Smoking must be at least 20 pack‑years, and if smoking has ceased, the clinical onset must occur within five years of cessation (s 8(3); Schedule 1). Similarly, alcohol exposure is at least 320 grams per week for six months within one year prior to clinical onset (s 8(4)), with the note that Australia’s standard drink is 10 grams. Glucocorticoid exposure requires meeting cumulative dose and average rate thresholds set out in Schedule 1. Failure to document exposures in the exact units used by the Statement may lead to rejected claims.

3. Glucocorticoid thresholds are specific and non-intuitive

• The Schedule lists both minimum cumulative doses and minimum average rate per day for multiple glucocorticoids. If a claimant’s steroid exposure falls short of either the cumulative minimum or the average rate requirement, the “glucocorticoid therapy as specified” factor is not satisfied. Clinicians must convert various steroid regimens into equivalent doses per the table to show compliance with the Schedule’s requirements.

4. Osteonecrosis of the jaw has a separate factor set

• Section 8(24) lists specific factors for osteonecrosis of the jaw, including diabetes, recent periodontal disease, syphilitic palatine gumma, recent acute herpes zoster involving the trigeminal nerve, cocaine-related substance use disorder, prolonged osteoclast inhibitor treatment with last dose within two years, and antiangiogenic agent treatment for at least six months with last dose within two years. A claimant alleging osteonecrosis of the jaw must tailor evidence to these narrower criteria.

5. Some factors require contemporaneous diagnosis

• Several factors require the condition to be present “at the time of the clinical onset” (for example, solid organ malignancy, autoimmune disorders, haematological diseases, hypercoagulable state, dyslipidaemia, Cushing syndrome, HIV infection; s 8(5)-(12), (10) etc.). Practitioners must show those comorbidities were present at the moment of clinical onset, not merely historically or subsequently.

6. Factor 8(25) has a constrained application

• Inability to obtain appropriate clinical management only applies where osteonecrosis was suffered or contracted before or during relevant service, and did not arise out of service (s 9(2); s 8(25)). This prevents use of the factor for cases where osteonecrosis first arose out of service and later management was inadequate during service. The statutory text narrows the temporal and causal reach of this factor.

7. Drug exposure windows are tight for some therapies

• Certain drugs require very short windows, for example bevacizumab, denosumab or testosterone within 30 days before clinical onset (s 8(16)), while osteoclast inhibitors and antiangiogenic agents for jaw osteonecrosis impose longer treatment duration and last-dose windows (s 8(24)(f)-(g) and Schedule 1 note). Accurate medication records with dates are therefore essential.

8. Hyperbaric and diving definitions are specific

• “Hyperbaric exposure as specified” includes diverse activities with particular duration, depth and repetition criteria (Schedule 1). For example, breath-hold diving must be at least five metres for at least one minute on at least ten occasions within six months to qualify. Casual or occasional diving may not meet the precise thresholds.

9. ICD codes do not control meaning

• Although codes are listed in s 6(3), the statutory meaning is the definition in s 6(2). Practitioners cannot rely solely on ICD coding on a medical record; they must document the pathophysiology consistent with the definition of osteonecrosis in s 6(2).

10. Examples are non-exhaustive

• Schedule 1 definitions include examples (for antiangiogenic agents and osteoclast inhibitors) and state that lists are not limited to those examples. However, absence of a drug from an example does not mean it is excluded. Advisers should document mechanism of action and therapeutic class if relying on such drugs.

11. Interplay with other Statements can complicate proof

• If an s 8 factor refers to another injury or disease that has its own Statement of Principles, the other Statement governs that aspect (s 10). Practitioners must locate and apply that other Statement, which may have different thresholds and definitions, rather than assuming the present Statement supplies all necessary criteria.

12. The instrument is silent on appeal processes and evidentiary thresholds beyond the balance of probabilities

• The Statement speaks only to medical causation. Procedural protections, review rights and evidentiary rules applicable in claim adjudication are not set out here and must be checked in the VEA, MRCA and administrative practice.

In sum, the instrument’s technical precision creates evidentiary traps: failure to convert and document exposures in the exact units, omissions of onset dates, or reliance on non-specific clinical records can lead to rejection even where a claimant has a plausible medical case. Advisers should anticipate and fill these evidentiary gaps proactively.

Compliance, in practice, means presenting medical and other evidence that aligns precisely with the Statement’s definitions, thresholds and temporal windows and establishing a link between the relevant qualifying factor and the person’s relevant service. Below are pragmatic steps for claimants, legal advisers and clinicians to prepare claims consistent with the instrument.

1. Identify whether the claim falls under the Statement

• Confirm the claim is one to which section 120B of the VEA or section 339 of the MRCA applies (s 4). Verify that the person’s period of service qualifies as “relevant service” per Schedule 1 (eligible war service other than operational, defence service other than hazardous and British nuclear test defence service, or peacetime service under the MRCA). If not, the Statement does not apply.

2. Determine the clinical onset date and document it

• Because most factors are time‑bound to the “clinical onset of osteonecrosis,” obtain and document a clear clinical‑onset date supported by records. Where possible, secure specialist reports that identify the first symptom, first clinical diagnosis, first diagnostic imaging indicating osteonecrosis or another clearly articulated onset marker. Given the Statement does not define “clinical onset,” be explicit in clinical reports why the chosen date represents onset.

3. Map evidentiary requirements to the s 8 factors

• Review the s 8 list and identify which factor(s) best match the clinical history. Then map evidence to the Schedule 1 definitions and thresholds, for example:
  • Glucocorticoid therapy as specified: compile all prescription, dispensing and administration records for glucocorticoids; convert to equivalent doses using the Schedule 1 table to demonstrate both cumulative dose and minimum average rate where required.
  • Smoking: document lifetime smoking history and calculate pack‑years per Schedule 1; if smoking ceased, document cessation date to check the five‑year window.
  • Alcohol: assemble history and, where available, contemporaneous notes or statements quantifying weekly consumption in standard drinks and convert to grams (10g per standard drink).
  • Drugs: obtain medication charts and oncological or endocrine notes showing dates of administration for bevacizumab, denosumab, testosterone, antiangiogenic agents or osteoclast inhibitors, and show they fit the time windows in s 8(16) and s 8(24).
  • Medical comorbidities: secure specialist letters and test results validating diagnoses such as dyslipidaemia (laboratory lipid values per Schedule 1), chronic renal failure (GFR, dialysis records), hypercoagulable states (specific test results), autoimmune and haematological diseases (diagnostic criteria or specialist opinions).
  • Trauma/fracture: provide hospital records, imaging, operative notes demonstrating blunt/penetrating trauma, fractures, joint dislocation or subluxation within two years prior to clinical onset.

4. Address osteonecrosis of the jaw specifics

• For jaw cases, gather dental and ENT records for periodontitis, periodontal abscesses, dental pulp and apical disease within three months before clinical onset, and records for syphilitic palatine gumma or trigeminal herpes zoster within the stated windows. If alleging drug-induced jaw osteonecrosis, document duration of osteoclast inhibitor or antiangiogenic agent treatment and date of last dose.

5. For s 8(25) inability to obtain appropriate clinical management claims

• Demonstrate that osteonecrosis predated or coincided with service and did not arise out of service. Provide contemporaneous service medical records, references to unavailability of care, referral records, evacuation logs or correspondence showing that appropriate clinical care was not accessible during relevant service and that lack of management materially contributed to or aggravated the condition.

6. Cross‑reference other Statements where required

• If a factor invokes another injury or disease that has its own RMA Statement, obtain and apply that Statement’s criteria (s 10). For example, if an s 8 factor refers to an autoimmune disorder, and that autoimmune disorder is the subject of a separate Statement, compile evidence that meets the other Statement’s requirements in addition to this Statement.

7. Use precise laboratory and diagnostic data

• Where Schedule 1 sets numerical thresholds (dyslipidaemia, chronic renal failure GFR cut-offs), include laboratory reports, imaging, biopsy results and specialist documentation confirming those values at the relevant times. Generic statements that a patient had “abnormal lipids” will not satisfy the specific thresholds in Schedule 1.

8. Prepare medico-legal reports that convert to Schedule units

• Experts should explicitly perform conversions required by the Statement: steroid equivalence calculations, pack‑year computations, alcohol grams per week, and drug duration calculations. Reports should state how each fact satisfies the precise Schedule 1 definition or threshold.

9. Anticipate and document the relationship to relevant service

• The Statement requires the factor be related to relevant service (s 9(1)). Evidence may include service medical records showing exposure or diagnosis during service, incident reports, deployment medical notes, or contemporaneous civilian medical records that tie clinical events to dates coinciding with service. For exposure during or proximate to service, ensure records clearly link the exposure to the service time-frame.

10. Where clinical records are sparse, obtain corroborative statements

• If original clinical records are unavailable or incomplete, obtain corroborative evidence such as sworn statements, unit logs, allied health notes or employer records that can assist in reconstructing exposure histories. However, corroborative material should be as precise as possible because of the Statement’s numerical thresholds.

11. Prepare for potential cross‑examination of onset and exposure dating

• Because “clinical onset” is a potentially contested concept and many factors have tight windows, be prepared for decision-makers to scrutinise onset and exposure dating. Expert opinions should address why a chosen onset date is the appropriate marker against the Statement’s timeframes.

12. Check for other relevant RMA Statements and updates

• Before lodging or prosecuting a claim, check the RMA register for other Statements referenced by s 8 factors and for any amendments to this Statement after its commencement date. Ensure the most up-to-date versions are applied.

13. Keep documentation of death causation claims

• For death from osteonecrosis claims, secure the death certificate, autopsy reports, treating clinician opinions and records that connect osteonecrosis to the terminal event listed in Schedule 1 (for example, pneumonia or respiratory failure). Demonstrate that osteonecrosis contributed to the terminal event as required by s 6(5).

14. Collate a focused evidence bundle

• Assemble a structured evidence bundle that maps each s 8 factor relied upon to the specific documents or expert paragraphs proving it, including dates, units and calculations. This reduces the risk of administrative rejection for lack of specificity.

Following these steps will not guarantee acceptance of a claim, as ultimate decision‑making rests with the relevant statutory adjudicator applying the VEA/MRCA. However, the Statement is deliberately precise. Compliance means matching that precision in the evidentiary materials presented.