Statement of Principles concerning osteoporosis (Balance of Probabilities) (No.67 of 2024)

The SoP operates as a medical‑factual rulebook: it defines the kind of injury or disease (osteoporosis and death from osteoporosis), prescribes the clinical criteria that constitute that condition for the purposes of veterans’ compensation law, enumerates specific factors that can link the condition to relevant service, and provides dictionary definitions to render those factors objectively assessable. Key concepts are:

• Definition of osteoporosis (s 7(2)). The instrument adopts a systemic disease definition with three alternative objective indicators: (i) low bone mineral density (BMD) defined as a T‑score ≤ −2.5; (ii) radiologically confirmed fragility fracture or loss of ≥20% vertebral height due to fragility fractures; or (iii) anyone over 70 years with low BMD, or people with low bone density taking glucocorticoids for at least 3 months. The instrument excludes several bone pathologies (localised osteoporosis, Paget disease, osteomalacia, osteonecrosis, osteomyelitis, bone neoplasms, osteogenesis imperfecta) (s 7(2)(a)-(b)). The SoP notes that although osteoporosis attracts ICD‑10‑AM codes M80, M81 or M82, for application of the SoP the given definition controls (s 7(3)-(4)).

• Death from osteoporosis (s 7(5)). The SoP expressly includes death from a terminal event or condition that was contributed to by osteoporosis; the Dictionary lists examples of terminal events (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function) (Schedule 1: terminal event).

• Balance of probabilities standard (s 8). The RMA states its view, on sound medical‑scientific evidence, that osteoporosis and death from osteoporosis can be related to relevant service on the balance of probabilities. The SoP thus provides the medical basis that decision‑makers use under the relevant VEA/MRCA provisions.

• Factors that must exist (s 9). The SoP contains a closed list of factors; at least one must be present for a medical link to be established. These factors include specific chronic diseases (rheumatoid arthritis, ankylosing spondylitis, HIV, multiple sclerosis, Parkinson disease, myeloma, systemic mastocytosis, haemochromatosis), renal impairment thresholds (GFR <30 ml/min/1.73 m2 for ≥3 months), transplants, endocrine abnormalities with defined duration windows, certain gastrointestinal diseases, surgical procedures (gastrectomy/Roux‑en‑Y bypass ≥1 year prior), pregnancy (for minimal trauma fracture only, within 3 months), anorexia nervosa, glucocorticoid and other medication exposures meeting quantitative dose and duration thresholds, tobacco and alcohol exposure thresholds, nutritional deficiencies and altered dietary patterns with specified duration and thresholds, cadmium exposure with renal damage or urinary cadmium ≥0.5 µg/g creatinine for ≥5 years, severe immobility definitions and physical activity thresholds, BMI <20 for specified durations, specified weight loss, and inability to obtain appropriate clinical management prior to worsening (s 9).

• Relationship to service (s 10). Presence of any listed factor must be related to the person’s relevant service. The clinical‑worsening aspects of factors only apply to material contribution or aggravation where the person’s osteoporosis pre‑existed or was suffered during (but did not arise out of) the relevant service (s 10).

• Cross‑reference to other SoPs (s 11). If a factor refers to an injury or disease covered by another SoP, the terms of that other SoP apply in accordance with that instrument as in force.

• Conversion rules and objective thresholds (Schedule 1). The Dictionary supplies precise calculations and equivalence factors: dose equivalence to prednisolone (multipliers for various glucocorticoids), pack‑year rules (including an equivalence table for non‑cigarette tobacco), the biochemical thresholds for vitamin D and vitamin C deficiency, urinary cadmium criteria, MET definitions for physical activity, concrete dose and duration minima for an enumerated medication table, and the BMI formula (Schedule 1).

These concepts make the SoP a rules‑based device that converts clinical heterogeneity into discrete thresholds for administrative decision‑making under the VEA and MRCA. The RMA’s medical view supplies the causal link on a probabilistic standard, but the statutory nexus to relevant service remains a separate requirement (s 10).

Primary affected parties:

• Veterans and members of the Forces lodging claims under the VEA (s 120B) or MRCA (s 339): The instrument applies to claims to which those provisions apply (s 5). Any claimant advancing a service connection argument for osteoporosis or death from osteoporosis will be assessed against the criteria in this SoP.

• Decision makers in the Department of Veterans’ Affairs and the Military Rehabilitation and Compensation Commission: They must apply the RMA’s SoP when determining causation issues for covered claims. The SoP supplies the medical thresholds and factors that constitute a medical link; decision makers will use these to accept or reject a claim’s medical nexus element.

• Treating clinicians and medical experts preparing evidence: The SoP specifies the exact clinical, biochemical and exposure metrics required. Treating clinicians who provide opinions, records or investigations (DXA scans with T‑scores, radiology for fragility fractures, serum 25(OH)D levels, urinary cadmium, GFR values, drug prescriptions/dispensing histories, transplant records, psychiatric diagnostic criteria for anorexia nervosa, etc.) will shape the success or failure of claims.

• Legal advisers, advocates and claims preparers: The SoP converts many issues of causation into questions of measurable fact, so lawyers and advocates will focus on assembling documentary proof that one or more enumerated factors existed and were related to relevant service (see s 9 and Schedule 1).

Secondary affected parties and service providers:

• Hospitals, pathology services, radiology clinics and pharmacies: The SoP’s thresholds require documented laboratory values (e.g., serum 25(OH)D <50 nmol/L for 2 years within 5), urinary cadmium readings, GFR calculations, DXA T‑scores, and pharmacy dispensing histories to calculate cumulative glucocorticoid and other medication doses, and to verify minimum durations. These records are evidence sources that claims will need to access.

• Primary care and specialist services, particularly endocrinology, rheumatology, oncology, haematology and transplant units: The SoP lists conditions managed by specialists (myeloma, systemic mastocytosis, Cushing syndrome, hyperparathyroidism, type 1 diabetes, solid organ transplants, etc.), so specialist documentation will be material.

• The Repatriation Medical Authority: It issued the SoP and will periodically update SoPs; repeal of the 2014 SoP (s 4) changes the medico‑legal landscape for claims after commencement.

Who bears the burdens and costs:

• Claimants bear the evidentiary burden to show that a listed factor existed and was related to their relevant service (s 9 and s 10). That will often require gathering historical records , medication dispensing, lab results, hospital notes, employment/service medical records , and may entail time and expense.

• The Department of Veterans’ Affairs bears administrative costs in applying the new SoP, updating claim processing templates, training staff to interpret dose equivalence calculations and the Schedule’s medication table, and procuring expert medical input where records are incomplete.

• Treating practitioners may incur administrative work supplying precise dose totals, conversions to prednisolone equivalence (Schedule 1) and compiled histories.

Potential distributional outcomes:

• Claimant predictability increases where applicants can document the objective thresholds set by the instrument (e.g. cumulative glucocorticoid thresholds, biochemical values). Conversely, claimants with plausible clinical osteoporosis but without documentary evidence meeting the SoP thresholds may face rejection, increasing their need for medical records retrieval and legal assistance.

• Veterans whose osteoporotic risk is driven by excluded bone diseases (per s 7(2)(b)) will not be deemed to have osteoporosis for the purposes of this SoP, even though they may have clinically significant bone pathology; those conditions may fall under other SoPs or be outside the RMA framework.

This SoP creates clear medical thresholds and obligations for decision‑makers and delineates the factual matters claimants must establish; it does not itself create statutory rights of payment or specific enforcement mechanisms, but it informs the medical causation element of entitlement decisions under the VEA and MRCA.

Duties and obligations imposed or implicated by the instrument:

• Decision‑maker obligation to apply the SoP: Where a claim is “to which section 120B of the VEA or section 339 of the MRCA applies” (s 5), decision‑makers must consider the RMA’s SoP when assessing whether osteoporosis or death from osteoporosis is connected with service. The instrument supplies the medical factors used to make that assessment (s 9). The SoP therefore functions as the RMA’s binding medical guidance to administrative decision‑makers.

• Duty to require relationship to service: It is not enough that a factor listed in s 9 exists; the existence of the factor must be related to the person’s relevant service (s 10(1)). Decision‑makers must therefore develop evidence linking the factor to service, for example proof that exposure occurred during service, or that service caused the factor.

• Clinical‑worsening limitation: The clinical worsening aspects of factors in s 9 apply only to material contribution to, or aggravation of, osteoporosis where the osteoporosis was suffered or contracted before or during (but did not arise out of) the relevant service (s 10(2)). Decision‑makers must apply this temporal limitation where the argument is that service aggravated an existing condition.

• Cross‑application of other SoPs: If a factor in s 9 refers to another injury or disease covered by another SoP, the terms of that other SoP apply “in accordance with the terms of that Statement of Principles as in force from time to time” (s 11). There is thus a duty to consult and apply other relevant SoPs where applicable.

Rights or practical consequences for claimants:

• If a claimant establishes, on the balance of probabilities, that one or more factors in s 9 existed and were related to relevant service, the RMA’s medical view supports a finding that osteoporosis or death from osteoporosis can be service‑connected (s 8). That medical link is a central element of entitlement decisions under the VEA and MRCA.

• Claimants have a right to rely on objective thresholds specified in the Schedule 1 Dictionary (for example, DXA T‑scores, biochemical values, dose equivalence multipliers) to frame evidence and expert opinions. The Schedule converts many clinical questions into quantifiable measurements.

What the instrument does not do (limits and non‑duties):

• The instrument does not itself adjudicate entitlement, award compensation, or set amounts: those decisions are made under the VEA/MRCA by the relevant administrative and judicial bodies using the SoP as medical guidance (s 5). The SoP does not specify procedures, appeal rights or compensation rates.

• The SoP does not create criminal penalties or civil remedies; it is a medical determination instrument under s 196B(3) VEA (s 3).

Operational consequences:

• Practitioners preparing medical reports must align their opinions with the SoP’s objective thresholds if claimant success is to be optimised. For example, where a claimant’s argument is glucocorticoid‑induced osteoporosis, reports must quantify cumulative doses and provide date ranges enabling conversion per the Schedule 1 “dose equivalence to prednisolone” multipliers (s 9(12) and Schedule 1).

• Decision‑makers must assess both the factual existence of a listed factor and its service nexus; the SoP removes some medical uncertainty by setting thresholds but leaves the service connection as an evidentiary question.

The Statement of Principles is an administrative medical instrument; it does not itself prescribe criminal penalties, civil fines, or enforcement provisions. The document’s operational effect is to guide administrative decision‑making about veterans’ entitlements, not to penalise behaviour. The enforcement regime is therefore implicit and institutional rather than statutory within this instrument.

Direct enforcement mechanisms and consequences deriving from the SoP:

• Administrative accept/reject outcomes: The practical enforcement of the SoP occurs when decision‑makers under the VEA or MRCA accept or reject claims based on whether a claimant establishes, in accordance with the SoP, that osteoporosis or death from osteoporosis is connected with relevant service (s 5, s 8, s 9). Acceptance may lead to entitlement pathways under the VEA/MRCA; rejection means denial of those entitlements. The SoP itself does not set the procedural steps for review or appeal, which are governed by the underlying Acts and regulations.

• Evidentiary consequences: The Schedule and the detailed thresholds function as evidentiary gates: failure to produce proof meeting the numerical or temporal thresholds (for example, T‑score, cumulative glucocorticoid dose, urinary cadmium level, serum 25(OH)D values) can lead to claim denial. That is an indirect enforcement effect: the SoP raises the evidentiary bar by turning clinical causation into measurable criteria.

What the instrument does not do in enforcement terms:

• No penal sanctions. There are no fines, offences, or penal remedies in the SoP text. It neither criminalises misleading claims nor prescribes sanctions for non‑compliance by clinicians or departments; any penalties for false statements or fraud would reside in other statutory provisions beyond this instrument.

• No explicit administrative enforcement timetable or compliance monitoring. The SoP does not require auditors, compliance officers or reporting of its application; it simply provides the medical criteria that decision‑makers will use.

Implementation and practical enforcement risks:

• Reliance on documentary evidence: The SoP’s enforcement effect depends on the availability and verification of records. If records are missing, incomplete or ambiguous, administrative decision‑makers may need to commission independent medical opinions or may reject a claim where the threshold cannot be met on the available evidence. This creates operational workload for the Department and potential delay for claimants.

• Potential disputes over interpretation: While many criteria are numeric, some terms still require clinical judgment (for example, “inability to obtain appropriate clinical management” in s 9(27)). Disputes about interpretation may lead to administrative reviews and appeals under the VEA/MRCA regime, not to penalties within this instrument.

In short, the SoP enforces medical thresholds through the claim decision process; it does not itself impose statutory penalties. The practical consequences of non‑compliance with the SoP’s evidentiary thresholds are administrative denials of entitlement rather than criminal or civil penalties embedded in the SoP text.

This Statement of Principles operates within the statutory framework of veterans’ entitlements and compensation. The instrument explicitly situates itself under the VEA and MRCA, and it interacts with other pieces of law primarily through its application to claims and cross‑references to other SoPs.

Statutory basis and immediate statutory interactions:

• Made under subsection 196B(3) of the VEA (s 3). The RMA’s power under that subsection is the commanding legal authority for SoPs. The instrument also states that it applies to claims to which section 120B of the VEA or section 339 of the MRCA applies (s 5). Those sections in the parent Acts determine how an SoP is used in deciding causation issues; the SoP is thus a medical input into statutory decision‑making under the underlying Acts.

• Repeal of prior SoP (s 4). The 2014 Statement of Principles concerning osteoporosis (No. 99 of 2014) is expressly repealed. That is a direct interaction with the existing regulatory corpus: claims assessed after the commencement date will be determined in light of this new SoP rather than the 2014 instrument. The instrument does not itself supply transitional rules other than repeal and commencement (ss 2, 4).

Cross‑statutory and intra‑instrument interactions:

• Cross‑application of other SoPs (s 11). If a factor in s 9 refers to an injury or disease covered by another SoP determined under s 196B(3) of the VEA, the other SoP “applies in accordance with the terms” of that other SoP as in force. This creates hierarchical or lateral interplay: where a factor (for example, multiple sclerosis or myeloma) is the subject of its own SoP, practitioners and decision‑makers must consult and apply that separate SoP’s terms for the disease‑specific rules. Section 11 therefore mandates cross‑SoP coherence.

• ICD‑10‑AM codes and classification systems (s 7(3)-(4)). The SoP acknowledges that osteoporosis attracts ICD‑10‑AM codes M80-M82 but clarifies that for the purposes of the SoP the statutory definition in s 7(2) controls. The instrument references the independent hospital pricing authority’s ICD publication (s 7(4)). This is an interaction with diagnostic coding systems used elsewhere in health law and billing, but the SoP displaces reliance on coding alone; the substantive definition rather than ICD code governs causation for claims.

Potential downstream interactions and legal processes outside the SoP:

• Administrative law review and appeals: The SoP supplies a medical standard that decision‑makers apply. Where claimants disagree with decisions, appeals or judicial review proceedings under the VEA or MRCA appeals regime may ensue. The SoP will be part of the evidentiary and legal matrix in such proceedings. The instrument itself does not prescribe appeal rights , those rights are contained in the VEA/MRCA and related administrative law.

• Interaction with privacy, records production and evidentiary law: The SoP’s reliance on medical records, pharmacy dispensing data and laboratory results implicates legal regimes governing record access, patient consent and subpoena power in tribunals, though none of these are explicitly addressed in the SoP text. Practically, access to evidence required by the Schedule (e.g., urinary cadmium levels, serum 25(OH)D) will depend on rules under other statutes and agency policies.

• Interaction with other medical statutes and codes: The SoP’s exclusions list (s 7(2)(b)) references conditions that may be covered under other SoPs, or treated under non‑veteran compensation frameworks. The SoP confines its medical reach to the specified definition of osteoporosis; other legal frameworks may treat excluded conditions differently.

Points of legal friction or uncertainty that could produce disputes:

• The SoP defines the medical parameters but leaves the legal question of “related to relevant service” to the underlying statutory application (s 10). That separation may create litigation over whether factual linkages meet the statutory nexus standard even where the medical factor criteria are satisfied.

• The instrument requires application of other SoPs where factors overlap (s 11). Disputes could arise over which SoP governs particular facts if there is any semantic or temporal overlap between instruments.

Overall, the SoP is an intragovernmental instrument that feeds medical findings into the statutory decision‑making architecture of the VEA and MRCA. It relates to other laws through application in claims, reliance on external diagnostic codes, the cross‑SoP mechanism, and through the practical need for evidence governed by privacy and evidentiary rules outside the SoP.

This SoP is No. 67 of 2024 and it expressly repeals the prior Statement of Principles concerning osteoporosis No. 99 of 2014 (Federal Register of Legislation No. F2014L01391) (s 4). It is dated 20 August 2024 and commences on 24 September 2024 (s 2). The instrument is made under subsection 196B(3) of the VEA (s 3).

What the instrument records about amendment and supersession:

• Repeal: The 2014 SoP is removed from force when this instrument commences (s 4). The new SoP therefore supersedes and replaces the earlier medical criteria that decision‑makers previously applied.

• No other amendments or transitional provisions are contained within the instrument. The text does not include express savings, transitional application rules for claims lodged before commencement, or grandfathering provisions. The only change recorded is the repeal and the commencement date (ss 2, 4).

Implications of the recorded amendment:

• From the commencement date, decision‑makers are to apply the 2024 SoP in determining relevant claims to which s 120B VEA or s 339 MRCA apply (s 5). Because there are no express transitional clauses in this instrument, practitioners should assume the new SoP governs assessments conducted after commencement; whether earlier decisions or appeals made under the 2014 SoP are revisited will depend on the VEA/MRCA procedural rules and administrative practice outside the instrument.

• The Schedule 1 Dictionary has been updated with specific technical conversions and thresholds (for example, dose equivalence multipliers and an expanded medication table). These changes can materially affect claim outcomes by changing the measurement rules for exposures and durations.

What the instrument does not disclose about amendment history:

• No prior amendment chronology is included beyond the explicit repeal of the 2014 instrument. The instrument does not set out RMA deliberations or prior drafts, nor does it list consultative inputs or explanatory material within the text provided. Any further legislative or administrative amendments after commencement will be published separately by the RMA.

Practical consequences for practitioners tracking change:

• Legal advisers and clinicians should treat the 2014 SoP as replaced with effect from 24 September 2024, and must reconcile past decisions or pending claims with the new thresholds and definitions in Schedule 1.

• Because the instrument includes precise numerical thresholds and conversion rules, it is necessary to check whether the new Schedule alters how exposures and medications were previously counted under the 2014 instrument (for example, different dose equivalence multipliers or revised medication lists and minimum durations). The instrument itself contains the operative rules for the 2024 SoP.

The Statement of Principles instrument contains no litigation history, case citations, or references to judicial determinations. It does refer to classification codes (ICD‑10‑AM) and diagnostic manuals (DSM‑5‑TR) for definitional purposes (s 7(3)-(4); Schedule 1). Beyond that, the instrument does not purport to summarise or rely on any particular legal determinations, cases or appeals.

Practical implications of the absence of litigation history in the instrument:

• There are no judicial interpretations recorded within the instrument to guide application of ambiguous provisions or contested thresholds. That leaves contested interpretative questions , for example the application of s 10(2) clinical‑worsening limits, or the correct calculation of cumulative glucocorticoid dose using Schedule 1 multipliers , to be resolved in administrative practice or, if necessary, by appeals and judicial review under the VEA/MRCA regimes.

• Where claimants, decision‑makers or advisors anticipate controversy, they should prepare to argue the meaning of the SoP’s provisions in the context of administrative decision‑making and appeal processes available in the VEA and MRCA. The instrument itself does not set interpretative guidance beyond the text and the Schedule.

Areas likely to generate litigation or internal review, given the instrument’s content:

• Service nexus disputes: Even where a factor in s 9 is present on the facts, whether that factor is related to relevant service (s 10(1)) may be disputed. Such disputes touch core entitlement questions and are common grounds for administrative review and appeal.

• Application of the clinical worsening limitation: The clinical‑worsening aspects are limited to material contribution to, or aggravation of, pre‑existing osteoporosis where it “was suffered or contracted before or during (but did not arise out of) the person’s relevant service” (s 10(2)). The precise legal meaning of these temporal and causal constraints may be litigated.

• Interpretation and evidence of exposure thresholds: The Schedule specifies strict numerical criteria for exposures and durations (for example, urinary cadmium levels, serum 25(OH)D thresholds, cumulative glucocorticoid doses with two alternative time windows). Disputes are likely where records are incomplete, where conversion to prednisolone equivalence is contested, or where the reliability of historical exposure estimates is challenged.

• Overlap with other SoPs: Because s 11 requires application of other SoPs where a factor refers to another covered disease, disputes may arise over which SoP governs or how to reconcile overlapping provisions.

Because the instrument does not cite any cases, practitioners should not assert judicially established doctrines based on the SoP text alone. If litigation arises, the SoP will be a primary textual source for the medical element of claims, but legal outcomes will depend on procedural laws, administrative reasoning and any judicial interpretation of the VEA/MRCA and the SoP’s application in specific factual contexts.

This SoP contains multiple specific numerical thresholds, conversion rules and temporal windows. Those features provide clarity where records exist, but they also create traps for claimants and advisers. Key “gotchas” to watch for are concrete and procedural; they concern evidence gaps, conversion complexities, temporal limitations, exclusions and cross‑SoP interactions.

1. Objective thresholds require documentary proof. Many factors are expressed as numerical or timing thresholds (e.g. T‑score ≤ −2.5; urinary cadmium ≥0.5 µg/g creatinine for ≥5 years; serum 25(OH)D <50 nmol/L for a continuous 2 years within the 5 years before onset; GFR <30 ml/min/1.73 m2 for ≥3 months; BMI <20 for a continuous 2 years within the 10 years before onset). Absent contemporaneous medical records, retrospective proof will be difficult and may be rejected (s 9; Schedule 1). The Dictionary’s pack‑year and alcohol calculations (see below) convert self‑report into quantified thresholds; poor recollection can be fatal to a claim.

2. Complex cumulative glucocorticoid rules. Section 9(12) lists multiple glucocorticoids with two alternative cumulative thresholds for each drug (a higher threshold over any duration, and a lower threshold within 6 months). The Schedule supplies dose equivalence multipliers to prednisolone (Schedule 1: dose equivalence to prednisolone). Practitioners must convert differing steroid types and dosing regimens into prednisolone‑equivalent totals and check which duration threshold applies. Mistakes in conversion or aggregation across prescriptions will undermine proof.

3. Medication list with precise duration minima. The “taking a medication from the specified list” definition in Schedule 1 enumerates particular drugs, routes, minimal doses and minimum durations (for example, tamoxifen (premenopausal women only) minimum 60 months; aromatase inhibitors minimum 12 months; anticonvulsants oral any dose for 24 months). Evidence must show not only the prescription but the route, dose and duration to meet the minimums. Topical exclusions (for some drugs) are specified; overlooking route details can defeat a claim (Schedule 1).

4. Alcohol thresholds expressed in kilograms of alcohol. Sections 9(15) and 9(16) set thresholds for males (220 kg alcohol within any 10 year period within the 20 years before onset) and females (110 kg alcohol). The instrument helpfully notes that alcohol consumption is calculated using the Australian standard of 10 grams per standard drink. But practitioners must perform the conversion (e.g. 220 kg = 220,000 grams = 22,000 standard drinks over 10 years) and then corroborate drinking histories with contemporaneous records where possible. Self‑report alone can be problematic.

5. Smoking calculation rules. The pack‑year definition in Schedule 1 contains equivalence rules for non‑cigarette tobacco types, and gives examples of pack‑year computations. Claimants who used pipes, cigars or roll‑your‑own tobacco must convert consumption into pack‑years using the equivalence provided (Schedule 1). Failure to read the equivalence note can produce under‑ or over‑estimation.

6. Interaction with other SoPs. If a factor refers to a disease that has its own SoP (for example, multiple sclerosis), s 11 requires application of that other SoP “as in force from time to time”. The practical effect is that a claimant cannot rely solely on the osteoporosis SoP where overlapping conditions are governed elsewhere. Advisers must check other SoPs for potentially stricter or different tests.

7. Exclusions matter. The SoP explicitly excludes certain bone pathologies (s 7(2)(b)). If a claimant’s bone disease is primarily one of the excluded conditions (Paget disease, osteomalacia, osteonecrosis, osteomyelitis, bone neoplasm, osteogenesis imperfecta, localised osteoporosis), the claimant does not have osteoporosis for the purpose of this SoP even if bone fracture or low density are present clinically. That can change entitlement pathways.

8. Clinical worsening temporal limit. The clinical‑worsening aspects of s 9 apply only when osteoporosis was “suffered or contracted before or during (but did not arise out of) the person’s relevant service” and then service materially contributed to or aggravated it (s 10(2)). This is a narrow channel for claims of aggravation; if osteoporosis first arose out of service, this particular clinical‑worsening route is not available.

9. “Inability to obtain appropriate clinical management” is open‑ended. Section 9(27) includes inability to obtain appropriate clinical management as a factor. That is fact‑sensitive and may require substantial contemporaneous records (referrals, appointment attempts, waitlists) to substantiate. The SoP does not define “appropriate clinical management” in the Dictionary, so arguments will hinge on clinical standards and evidence.

10. Proving exposures occurring in service. Section 10 requires that the factor be related to relevant service. Many factors , smoking, alcohol, medication exposures, dietary patterns, vitamin deficiencies , may span service and civilian life. Claimants must produce service records, deployment health records, or contemporaneous clinical records to show the exposure’s timing and link to service.

11. Ambiguity in drafting. Some phrasings, for example in s 7(2) where a list of indicators is connected by commas and the word “and” appears before exclusions, create potential interpretative questions about whether certain alternatives are conjunctive or disjunctive. While the Dictionary clarifies many elements, administrative disputes may arise around ambiguous syntax.

12. Reliance on laboratory thresholds that require sustained values. For vitamin D the SoP requires a serum 25(OH)D level of less than 50 nmol/L for a continuous period of at least 2 years within the 5 years before onset (s 9(20) and Schedule 1). Sustained laboratory evidence over two years is uncommon unless the claimant was repeatedly tested, so claimants may struggle to meet this requirement without serial data.

13. Age and T‑score interplay. The SoP’s definition includes an age‑based clause: “anyone over 70 years with a low bone mineral density” counts. Practitioners must be careful to combine age and T‑score evidence correctly rather than relying on age alone.

In practice, these “gotchas” turn the SoP into a checklist that requires precise documentation. Legal advisers should audit client records against the SoP’s numeric criteria before lodging or litigating claims. Clinicians should be asked to supply converted totals (for steroid equivalence and cumulative exposure) and serial laboratory values where available.

Compliance in this context means assembling evidence and structuring medical/legal submissions so that decision‑makers can apply the SoP and conclude, on the balance of probabilities, that osteoporosis or death from osteoporosis is connected to relevant service (ss 5, 8, 9, 10). Below is a task‑oriented checklist for claimants, clinicians and advisers, with pointers to the specific SoP provisions that require particular types of evidence.

1. Establish the SoP definition of osteoporosis or death from osteoporosis (s 7).

• Confirm the diagnostic pathway: obtain DXA scan reports showing T‑score ≤ −2.5 (Schedule 1: low bone mineral density), or radiology confirming fragility fracture or documented loss of ≥20% vertebral height, or if age >70, evidence of low BMD. If claiming death from osteoporosis, secure death certificate, clinical summaries and evidence that osteoporosis contributed to the terminal event (s 7(5) and Schedule 1: terminal event).

• Exclude listed differential diagnoses. If bone pathology could be Paget disease, osteomalacia, osteonecrosis, osteomyelitis, bone neoplasm or osteogenesis imperfecta, gather specialist reports to rule those conditions in or out (s 7(2)(b)).

2. Identify which factor(s) in s 9 apply and gather targeted evidence.

• Chronic disease diagnoses (s 9(1)-(5), (21), (23), (24)): Obtain specialist letters, diagnostic tests and records indicating onset date and duration. For example, rheumatoid arthritis or ankylosing spondylitis requires documentation showing diagnosis at least 2 years prior to clinical onset or worsening (s 9(1)). For chronic renal impairment require GFR values <30 ml/min/1.73 m2 for at least 3 months (s 9(4)).

• Transplant and surgical history (s 9(6), (9)): Obtain operation reports, discharge summaries and clinic letters confirming dates. For gastrectomy/Roux‑en‑Y, ensure the procedure occurred at least one year before onset (s 9(9)).

• Endocrine and gastrointestinal disease (s 9(7), (8)): Gather endocrine test results and specialist correspondence indicating duration. Many endocrine abnormalities require continuous periods for definitional thresholds (e.g. 2 years within the 5 years).

• Pregnancy and minimal trauma fracture (s 9(10)): For minimal trauma fracture claims check maternity records or obstetric notes establishing pregnancy within 3 months before onset.

• Anorexia nervosa (s 9(11) and Schedule 1): Secure psychiatric assessments that meet the DSM‑5‑TR diagnostic criteria set out in the Dictionary.

3. Document medication exposures precisely.

• Glucocorticoid exposures (s 9(12) and Schedule 1). Compile pharmacy dispensing records, inpatient medication charts and prescription histories. Convert different steroids to prednisolone equivalents using Schedule 1 multipliers. Calculate the two relevant cumulative totals (within 6 months and over any duration) and produce a table showing the conversion and cumulative totals for the decision‑maker.

• Medications on the specified list (Schedule 1 table). For each listed medication, gather prescription/dosing records and show that minimum duration thresholds are met (for example, tamoxifen 60 months in premenopausal women; anticonvulsants 24 months). Also document route of administration and exclusions (some entries exclude topical routes).

4. Quantify and corroborate lifestyle exposures.

• Smoking (s 9(14) and Schedule 1). Prepare a smoking history and convert it into pack‑years using the Schedule’s formula and equivalences for non‑cigarette tobacco. Provide corroborative records where available (military medical records, general practice notes, respiratory clinics).

• Alcohol (s 9(15)-(16)). Convert self‑reported consumption into kilograms of alcohol using the Australian standard (10 g per standard drink). Produce a calculation showing total kilograms in any 10‑year window within the relevant 20‑year period and corroborate with health records, ICD codes for alcohol use disorders or other contemporaneous notes if possible.

• Diet and vitamin intake (s 9(17)-(20)). For altered dietary patterns and low calcium intake, compile dietitian assessments, nutritional histories, and any recorded dietary evaluations. For vitamin D deficiency document serial serum 25(OH)D values showing <50 nmol/L sustained for 2 continuous years within the previous 5 years. For severe vitamin C deficiency use serum ascorbic acid <2.5 mg/L or clinical scurvy signs (Schedule 1).

5. Compile laboratory and imaging evidence.

• DXA scans and radiology to establish low BMD or fragility fractures (s 7 and Schedule 1).

• Serial serum 25(OH)D, serum ascorbic acid, urinary cadmium and creatinine to calculate µg/g creatinine, and GFR values with dates (s 9(4), (20), (19), (22) and Schedule 1).

• Pathology confirming myeloma, systemic mastocytosis, haemochromatosis where those factors are relied upon (s 9(5), (21) and Schedule 1).

6. Demonstrate relationship to relevant service (s 10).

• Produce service medical records, deployment health assessments, and contemporaneous service documents showing when exposures, diagnoses or treatments occurred in relation to the period of relevant service as defined in Schedule 1 (relevant service means eligible war service, defence service, or peacetime service under the MRCA).

• For aggravation claims under s 10(2), produce medical records establishing that osteoporosis pre‑existed or was suffered or contracted before or during service and then identify service events that materially contributed to or aggravated the condition.

7. Address ambiguous or qualitative factors.

• Inability to obtain appropriate clinical management (s 9(27)). Document attempts to obtain care: referral letters, appointment cancellations, correspondence, waitlist evidence and correspondence with health providers.

• Physical activity thresholds and immobility (s 9(23)-(24)). Use clinical notes, rehabilitation assessments, physiotherapy reports and objective MET calculations where possible to show inability to undertake activity greater than three METs or prolonged bed rest/paralysis.

8. Prepare expert reports that map facts to the SoP.

• Instruct treating specialists to directly address the SoP: identify the precise s 9 factor relied upon, provide the factual and temporal basis, reference the Schedule conversion calculations (for steroid equivalence and pack‑year/alcohol computations), and opine on whether the factor is related to relevant service.

• Ensure experts expressly address the s 10 service nexus and the s 10(2) aggravation limitation where relevant.

9. Where factors intersect with other SoPs, consult them (s 11).

• If a relied factor is the subject of another SoP, obtain and apply that other SoP’s terms; include cross‑references in submissions and explain how the facts satisfy both instruments where applicable.

10. Anticipate gaps and remedial steps.

• If records are incomplete, obtain statutory medical record releases, search hospital and defence records, and consider sworn statements confirming exposure histories. Be ready to explain the absence of specific serial tests where continuous measurements are required (for example, vitamin D).

• Where numerical conversion is required (steroid equivalence, alcohol kilograms, pack‑years), include a worked calculation annex using Schedule 1 multipliers so decision‑makers can verify the arithmetic without re‑converting.

11. File evidence in clear, tabulated form.

• Present a short summary table at the front of any submission that lists each s 9 factor relied upon, the documentary evidence (with dates), the Schedule computations (for steroid, tobacco, alcohol), and the service link evidence. This reduces administrative friction and the risk of misapplication.

12. Keep an eye on timing.

• The SoP commences on 24 September 2024 and repeals the 2014 SoP (ss 2, 4). Confirm which SoP applies to a particular claim and note that other SoPs may be updated “from time to time” per s 11; maintain currency checks.

Compliance involves translating clinical narratives into the quantifiable thresholds the SoP demands, documenting the service nexus, and structuring submissions so that decision‑makers have the specific measurements and conversion work already done. That reduces the risk of administrative rejection on evidentiary technicalities and aligns medical opinion with the RMA’s instrument (ss 7-11; Schedule 1).