Statement of Principles concerning steatohepatitis (Balance of Probabilities) (No. 87 of 2022)

The central concept is the “Statement of Principles”, a legislative instrument that codifies the RMA’s view of the medical-scientific evidence linking a condition to service. The standard of proof here is “balance of probabilities” (civil standard), as distinct from the “reasonable satisfaction” standard used for operational service under the VEA. The instrument applies only to “relevant service”, which is defined in the dictionary as: (a) eligible war service (other than operational service) under the VEA, (b) defence service (other than hazardous service and British nuclear test defence service) under the VEA, or (c) peacetime service under the MRCA. This means that veterans with operational service or hazardous service cannot use this SoP; they would need a SoP made under subsection 196B(2) of the VEA (the reasonable-satisfaction standard). The distinction is critical because it affects which claims pathway a person follows.

“Steatohepatitis” is defined in subsection 7(2) as a histological diagnosis: fatty change and inflammation with hepatocyte injury, with or without fibrosis. It includes both alcoholic and non-alcoholic steatohepatitis but excludes four specific liver diseases. The definition therefore requires medical evidence of liver biopsy or other diagnostic confirmation, not merely elevated liver enzymes. The instrument equates death from steatohepatitis with death contributed to by a terminal event listed in the dictionary, effectively broadening the coverage when steatohepatitis was a contributory cause.

“Clinical onset” is not defined in the instrument but is a term of art in veterans’ law, meaning the time when the condition became clinically apparent - that is, when symptoms first manifest or when a diagnosis could first be made. The factors in section 9 refer to various temporal relationships: some must exist “at the time of” clinical onset (e.g., diabetes mellitus, obesity, dyslipidaemia); others must occur within a specified period before clinical onset (e.g., rapid weight loss within 18 months, alcohol consumption within any 5 year period, certain drug use for at least 30 days). This temporal precision imposes a burden on claimants to establish the timing of both the factor and the disease onset.

The “balance of probabilities” standard underlies the entire instrument. Section 8 states that the RMA is of the view, on the sound medical-scientific evidence available, that it is more probable than not that steatohepatitis and death from steatohepatitis can be related to relevant service. This is the evidentiary threshold for the factors themselves: they are considered capable of causing the disease, not proven to have done so in every case. Decision-makers then apply the factors to the individual claimant’s circumstances.

Section 10 requires that the existence of any factor must be “related to the relevant service rendered by the person”. This is a separate nexus requirement. A claimant might have obesity or dyslipidaemia, but if those conditions are not connected to their service (e.g., pre-existing and unrelated), the factor does not help. The relationship must be causal or contributory; the SoP does not define how strong the relationship must be, leaving that to general principles of veterans’ law. Factor 12 (inability to obtain appropriate clinical management) is specifically limited to cases of material contribution or aggravation where the steatohepatitis was suffered or contracted before or during (but did not arise out of) relevant service. This is a narrow window: it covers veterans who developed steatohepatitis before service, or during service but from a non-service cause, and then service-related circumstances prevented proper treatment, worsening the condition.

The dictionary defines several terms with precision. “Being obese” uses three alternative measures: BMI ≥30, waist circumference >102 cm (males) or >88 cm (females). This avoids relying solely on BMI, which can misclassify muscular individuals. “Rapid weight loss” is defined as a reduction of body mass by at least 20% within a continuous period of no more than six months. The note gives examples: anorexia nervosa, acute starvation, and surgery causing diarrhoea or malabsorption. “Dyslipidaemia” requires abnormal blood lipid levels evidenced by specific laboratory thresholds or regular administration of drug therapy to normalise lipid levels. This sets a clear, objective standard but may require claimants to have had blood tests at the relevant time.

Schedule 2 lists 26 specified drugs. The list includes common medications like beta-blockers, calcium channel blockers, glucocorticoids, methotrexate, tamoxifen, and valproate. Factor 10 requires that the drug “cannot be ceased or substituted”. This is a subjective judgment: a doctor might decide that a beta-blocker can be changed to another class, or that tamoxifen can be replaced with an aromatase inhibitor. The instrument does not define what makes a drug impossible to cease or substitute, leaving room for clinical disagreement and potential disputes in claims.

The primary affected group is current and former members of the Australian Defence Force (ADF) and their dependants who make claims for incapacity, injury, disease or death under the VEA or MRCA. Specifically, it affects persons who served in “eligible war service (other than operational service)” under the VEA - generally World War II veterans and certain other conflicts who served within Australia but not in combat zones; persons with “defence service (other than hazardous service and British nuclear test defence service)” under the VEA - generally peacetime defence service after 1972; and persons with “peacetime service” under the MRCA - most ADF members after 1 July 2004 who served in non-warlike or non-operational service. Veterans with operational service (e.g., Vietnam, Gulf War, Afghanistan) are excluded from this SoP because they fall under a different standard (reasonable satisfaction) and would use the counterpart SoP made under subsection 196B(2), if one exists.

Claimants must prove that steatohepatitis - including alcoholic and non-alcoholic steatohepatitis - is connected to their service. The SoP provides a presumptive pathway if they can show one of the factors existed and was related to service. This affects their eligibility for pension, compensation for medical expenses, and other benefits under the VEA and MRCA. Dependants claiming death benefits also rely on this SoP, as it defines death from steatohepatitis as including contributory terminal events.

Medical practitioners are affected indirectly. They must provide clinical evidence that the claimant had one of the factors (e.g., diabetes, obesity, dyslipidaemia, rapid weight loss, alcohol consumption at specified levels, or use of listed drugs). They may need to produce blood tests, anthropometric measurements, and medication histories. The definition of “being obese” requires waist circumference or BMI calculation, which may not be routinely recorded in service medical records. The definition of “dyslipidaemia” requires specific lipid panels or evidence of drug therapy. The alcohol consumption factor (7 and 8) requires estimating total alcohol intake in kilograms over a five-year period, which is difficult to certify precisely.

The Repatriation Commission and the Military Rehabilitation and Compensation Commission are the decision-making bodies. They must apply this SoP when assessing claims under the relevant provisions. The RMA itself is the body that determined the SoP; it does not adjudicate individual claims but sets the evidentiary standard. The Department of Veterans’ Affairs (DVA) case officers and delegates must evaluate whether a claimant meets a factor and whether that factor is related to service.

Drug manufacturers of the 26 listed drugs are affected in a limited sense: the listing signals that those drugs are recognised as potential causes of steatohepatitis, which may affect prescribing decisions in military medicine or medico-legal contexts. However, the SoP does not impose liability on manufacturers; it only addresses service connection.

Legal practitioners representing veterans and MRCA members must understand the SoP’s structure to advise clients on which factors to pursue. They need to gather evidence linking the factor to service - for example, if a veteran became obese due to service-related inactivity or medication, that relationship must be established separately. The “inability to obtain appropriate clinical management” factor (12) is likely to be contentious, as it requires showing that service circumstances prevented proper treatment for pre-existing steatohepatitis.

Taxpayers and the broader Australian community bear the financial cost of successful claims, as compensation is paid from consolidated revenue. The SoP expands the pool of eligible claimants compared to requiring case-by-case medical causation, so it increases public expenditure on veterans’ benefits. There is a trade-off: it reduces litigation and administrative costs by providing a standardised evidentiary framework, but it may also allow claims that would not succeed on strict scientific proof.

The SoP does not create duties or rights directly; it is an evidentiary instrument that defines how decision-makers must treat certain facts when determining service connection. The key “duty” is on the decision-maker (the Repatriation Commission, the MRCC, or a tribunal) to accept that a factor exists if the claimant proves it on the balance of probabilities and that the factor is related to relevant service. Section 9 states that at least one of the factors “must exist before it can be said that, on the balance of probabilities, steatohepatitis or death from steatohepatitis is connected with the circumstances of a person’s relevant service”. This is a mandatory condition: without a factor, the decision-maker cannot find connection under this SoP, though a claimant could still rely on other evidence outside the SoP (e.g., direct medical evidence of causation from a specific service exposure not listed). In practice, the SoP creates a strong presumption: if a factor is proved and related to service, the decision-maker is bound to accept the connection, subject to any contrary evidence.

Claimants have a right to have their claim assessed under this SoP if they fall within the definition of relevant service and the claim is for steatohepatitis. They are not required to prove causation from first principles; they need only establish one factor and its relationship to service. The burden of proof lies on the claimant on the balance of probabilities. The right to rely on the SoP is a procedural advantage, but it is not an entitlement to compensation.

The duty of the RMA is already discharged by making the SoP. The RMA must base its determinations on “sound medical-scientific evidence” (section 8), but that is a matter for the RMA’s internal processes, not reviewable in individual claims. The instrument recites that the RMA is of the view that steatohepatitis and death from steatohepatitis can be related to relevant service on the balance of probabilities.

Section 10 imposes a critical nexus requirement: “The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.” This means the factor itself must be service-related. For example, a veteran with obesity who became obese after service due to civilian lifestyle cannot use factor 2 unless the obesity is attributable to service (e.g., from service-related injury limiting mobility). Similarly, diabetes mellitus factor (1) must be service-related - the vast majority of type 2 diabetes is not service-related, so claimants would need to show service causation of the diabetes (likely through another SoP for diabetes). The relationship can be indirect: for instance, if a veteran developed diabetes as a result of service-related obesity, both the diabetes and the obesity could be linked to service.

Factor 12 (“inability to obtain appropriate clinical management for steatohepatitis”) has a special limitation in subsection 10(2): it applies only to material contribution or aggravation where the steatohepatitis was suffered or contracted before or during (but did not arise out of) the person’s relevant service. This means it cannot be used for initial onset of steatohepatitis; it only applies when a pre-existing steatohepatitis was worsened because service prevented proper treatment. The claimant must prove that the clinical management they should have received was not available due to service circumstances (e.g., deployment to a location without medical facilities, or denial of access to a hepatologist). This is a high bar.

Section 11 incorporates other SoPs by reference. If a factor refers to an injury or disease covered by another SoP, the factors in that other SoP apply. For example, factor 1 requires “having diabetes mellitus at the time of the clinical onset of steatohepatitis”. Diabetes mellitus is itself covered by a SoP. The claimant would need to satisfy the factors in the diabetes SoP to establish that the diabetes is service-related. This creates a cascading burden: proving steatohepatitis may require proving another disease first.

The instrument does not create any private rights of action or duties enforceable by individuals against the Commonwealth. It only governs administrative decision-making. The rights are procedural: to have the SoP applied correctly, to receive reasons, and to seek review of adverse decisions by the Veterans’ Review Board, the Administrative Appeals Tribunal, and the Federal Court.

The Statement of Principles itself does not impose any penalties or create any enforcement mechanisms. It is a legislative instrument that sets out evidentiary standards for claims. Non-compliance by a claimant simply means their claim will fail; there is no penalty for making a claim that does not satisfy the SoP, unless the claim is fraudulent. The relevant penalties for false or misleading statements in claims are found in the Criminal Code Act 1995 (Cth) (e.g., s 134.1 obtaining a financial advantage by deception, or s 136.1 false statements to a Commonwealth entity) and in the Veterans’ Entitlements Act 1986 itself (e.g., s 215 for false statements to obtain a pension). These are not mentioned in the SoP, so they are external to this instrument.

Enforcement of the SoP is through the claims determination process. If a decision-maker fails to apply the SoP correctly, the claimant can seek internal review and then merits review by the Veterans’ Review Board or the Administrative Appeals Tribunal. The tribunal must apply the SoP as binding law; it cannot substitute its own medical opinion for the RMA’s determination of the factors. If the tribunal errs in law, judicial review can be sought in the Federal Court under the Administrative Decisions (Judicial Review) Act 1977 (Cth) or the Judiciary Act 1903 (Cth).

The RMA’s role is not enforcement but determination. The RMA could, in theory, amend or revoke the SoP if new medical evidence emerges, but that is prospective. The SoP does not have sunset provisions; it remains in force until repealed (as it was repealed by a later instrument, No. 87 of 2022 replaced No. 80 of 2013). The RMA is subject to scrutiny through its annual report and parliamentary oversight, but there is no direct enforcement against the RMA.

For drug manufacturers, there are no penalties arising from the listing of drugs in Schedule 2. The listing is not a regulatory finding of defect or liability. It is purely an evidentiary factor for veterans’ claims. However, inclusion may affect prescribing patterns and could be cited in medical negligence cases, but that is beyond the scope of this instrument.

The “inability to obtain appropriate clinical management” factor (12) could be subject to abuse if claimants argue that any delay or failure in service medical care constitutes inability. The SoP does not define what is “appropriate” - that would be determined by reference to standard medical practice. There is no penalty for making a weak claim, but the administrative cost of processing unsupported claims falls on the DVA and the taxpayer.

The instrument does not create any regulatory enforcement body. The Repatriation Commission and the MRCC have internal compliance mechanisms to detect fraud (e.g., data matching, medical review), but those are separate from the SoP.

This SoP operates within a broader legislative framework. Its primary authorising law is subsection 196B(3) of the Veterans’ Entitlements Act 1986 (VEA). That subsection empowers the RMA to determine SoPs for the balance of probabilities standard. There is a corresponding provision, subsection 196B(2), for SoPs on the reasonable satisfaction standard. These two types of SoPs are mutually exclusive based on the claimant’s service category. A veteran with operational service cannot use this SoP; they must use the counterpart (if one exists, or rely on general causation evidence). The instrument explicitly applies only to claims under section 120B of the VEA and section 339 of the MRCA.

Section 120B of the VEA requires that a decision-maker must not determine that an injury, disease or death is service-related (or related to defence service) unless a SoP upholds the contention that the injury, disease or death can be related to that service. This SoP provides that connection for steatohepatitis on the balance of probabilities, but only for relevant service as defined. For operational service, the standard is reasonable satisfaction, and a different SoP would be required - if none exists, the decision-maker can use general medical evidence.

Section 339 of the MRCA similarly requires a SoP for claims under that Act. The MRCA has a different service classification structure (warlike, non-warlike, peacetime). This SoP applies only to peacetime service under the MRCA, as per the definition of “relevant service”. Members with warlike or non-warlike service under the MRCA would need a SoP under the reasonable satisfaction standard.

This SoP expressly repeals the earlier Statement of Principles concerning steatohepatitis No. 80 of 2013. That earlier instrument was made under the same provision and applied to claims made before 19 September 2022. The repeal means that claims determined after that date must use this new instrument. However, transitional provisions in the VEA may allow a claim lodged before commencement to be determined under the old SoP if that would be more favourable; the instrument does not address that, so general administrative law principles apply.

The dictionary in the SoP cross-references the MRCA and VEA, defining “MRCA” as the Military Rehabilitation and Compensation Act 2004 and “VEA” as the Veterans’ Entitlements Act 1986. It also defines “relevant service” with reference to those Acts. This means that changes to those Acts could indirectly affect the scope of this SoP. For example, if Parliament amended the definition of “peacetime service” under the MRCA, the SoP would automatically apply to the new definition without amendment.

Section 11 of the SoP provides that if a factor refers to an injury or disease covered by another SoP, the factors in that other SoP apply. This creates a pyramid: for factor 1 (diabetes mellitus), the claimant must satisfy the SoP for diabetes mellitus (presumably No. whatever for that condition). The SoP for diabetes would itself have factors that must be related to service. This can create a chain of causation that a claimant must prove. Similarly, dyslipidaemia (factor 6) might itself be caused by other conditions like obesity or diabetes, which would require their own SoPs. This interaction increases compliance burden and complexity.

The SoP also interacts with the general law of evidence. The balance of probabilities standard is the civil standard; the SoP does not displace it but provides a structured application. The dictionary defines “terminal event” in a limited way: pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function. This interacts with other SoPs for those terminal events - for example, if the terminal event is pneumonia, a separate SoP for pneumonia may also need to be considered. However, the SoP for steatohepatitis treats death from steatohepatitis as including deaths contributed to by those events, simplifying the link.

The instrument interacts with administrative law principles such as procedural fairness. Claimants must be given an opportunity to present evidence of factors and their relationship to service. The SoP does not confer any rule-making powers on the DVA; it is a binding instrument.

This instrument (No. 87 of 2022) was made on 23 August 2022 and commenced on 19 September 2022. It is a standalone replacement of the previous SoP concerning steatohepatitis No. 80 of 2013 (registered as F2013L01900). The repealing provision is section 4, which states that the 2013 SoP is repealed. The instrument does not contain any amendment history of its own, nor does it list any amendments between 2013 and 2022. The earlier 2013 SoP itself may have replaced an even earlier version, but that is not part of this source.

The RMA publishes new SoPs periodically as medical evidence evolves. The fact that this is “No. 87 of 2022” indicates it is the 87th SoP made in the 2022 calendar year; the RMA produces many such instruments covering different conditions. The numbering does not indicate sequential amendments of the same condition. The instrument is made under the same subsection 196B(3) as the 2013 SoP, and the repeal is complete - the old instrument ceases to have effect for claims determined after commencement. However, claims lodged before 19 September 2022 may still be determined under the old SoP if transitional provisions apply; the instrument is silent on that, so the usual rule is that the law in force at the date of decision applies, subject to any savings provisions in the VEA.

No versions of this instrument are listed in the source. There are no notes indicating any amendments between commencement and the date of the source (it is the original instrument as made). Future amendments could be made if the RMA reviews the medical evidence again. The instrument does not contain a review date.

The dictionary and Schedule 2 may be amended by later RMA determinations. For example, new drugs could be added to the Schedule based on updated evidence of hepatotoxicity. Such amendments would require a new legislative instrument. The instrument does not provide for automatic updating, unlike some tiered frameworks.

This specific Statement of Principles is a legislative instrument, not a court judgment. The instrument itself does not cite any case law. There is no litigation history recorded within the document. However, the predecessor SoP (No. 80 of 2013) may have been the subject of judicial review or appeals in the Administrative Appeals Tribunal (AAT) or Federal Court. Common issues that can arise in litigation over SoPs include: whether the RMA properly considered the sound medical-scientific evidence; whether the factors are arbitrary or unreasonable; whether the definitions are consistent with the VEA; and whether the decision-maker correctly applied the SoP to the facts. None of this is in the source.

The instrument’s definitions (e.g., “being obese”, “dyslipidaemia”) have specific numerical thresholds that could be challenged as not reflecting the best medical evidence. However, the AAT and courts generally defer to the RMA’s medical expertise unless the decisions are legally unreasonable. There may be cases where the relationship between a factor and service (section 10) is disputed, such as whether a pre-existing obesity was aggravated by service. The instrument does not mention any such cases.

Claimants may also litigate the issue of “inability to obtain appropriate clinical management” (factor 12) - for example, whether a service hospital’s failure to refer to a specialist constitutes inability. Again, no cases are cited.

The absence of cited cases is typical for a SoP. Practitioners would need to search databases for AAT decisions applying this specific instrument or its predecessor to understand how the factors have been interpreted.

Several provisions in this SoP create traps for unwary claimants and practitioners. First, the definition of “relevant service” is narrower than many expect. It excludes operational service and hazardous service. A Vietnam veteran with steatohepatitis may not qualify for this SoP if they have operational service; they would need the “reasonable satisfaction” counterpart. The source does not indicate whether such a counterpart exists for steatohepatitis. If it does not, the veteran cannot use any SoP and must prove causation by direct evidence, which is far more difficult.

Second, the timing requirements are precise. Factor 2 (“being obese at the time of the clinical onset”) does not simply mean the person was obese at any time; they must be obese precisely when the steatohepatitis first became clinically apparent. If the steatohepatitis onset was years before the obesity developed, the factor does not apply. Conversely, if a person lost weight after developing steatohepatitis, they might no longer satisfy the obesity definition at the time of claim, but the factor only needs to exist at onset. Claimants must prove onset date, which can be speculative without a clear diagnosis date.

Third, the alcohol consumption factors (7 and 8) use kilograms of alcohol over any five-year period before clinical onset. This is an unusual metric. One standard drink equals 10 grams of alcohol, so 75 kg equals 7,500 standard drinks over five years, which is roughly 4.1 drinks per day on average for males (40 kg for females is about 2.2 drinks per day). However, the factor does not require daily drinking; it is a cumulative threshold over any five-year period. A binge drinker could consume large amounts in a short period and still reach the threshold. The problem is proving intake in kilograms from service records, which rarely contain that detail. Claimants may need to rely on self-reporting, which can be challenged.

Fourth, factor 10 requires that the drug “cannot be ceased or substituted”. This is a medical judgment. A doctor might opine that a drug is essential and no alternative exists, but the DVA or tribunal could later find that another drug was available. For example, a patient on one of the 26 listed drugs (e.g., a beta-blocker or calcium channel blocker) might have had several alternative medications that could have been tried. The claimant must show that cessation or substitution was not possible at the time, not just that it was not convenient.

Fifth, the rapid weight loss factor (3) requires a 20% reduction in body mass within six months. That is a very high threshold - an 80 kg person would need to lose 16 kg in six months. Most cases of weight loss leading to steatohepatitis do not reach that level. The note lists extreme examples like anorexia nervosa, acute starvation, and major surgery causing malabsorption. Routine dieting or post-surgical weight loss is unlikely to qualify unless it meets the 20% threshold.

Sixth, the “inability to obtain appropriate clinical management” factor (12) only applies to aggravation of pre-existing steatohepatitis, not to initial onset. Moreover, it requires that the inability was due to service circumstances. This is a narrow opening: the steatohepatitis must have been present before or during service but not caused by service, and then the service environment prevented treatment. Proving that the Commonwealth’s failure to provide treatment worsened the condition is legally and factually difficult.

Seventh, the relationship between the factor and service under section 10 is often overlooked. Many claimants assume that if they have diabetes or obesity, it must be service-related. But if the diabetes is genetic and began before service, it is not related. The SoP does not define “related to” - it leaves that to general principles, which typically require a causal or contributory link. For service-acquired obesity (e.g., from an injury that caused immobility), the claimant must prove that injury was itself service-related, which may require another SoP.

Eighth, the dictionary defines “BMI” and “being obese” using three alternative criteria. A claimant who has a BMI of 29.9 (just below 30) but a waist circumference of 102 cm (for a male) qualifies because the definitions use “or”. However, the waist measurement must be taken at the time of clinical onset, which may not be recorded. Claimants should gather evidence of waist circumference or BMI from around that time; if unavailable, they may fail.

Ninth, the drug list in Schedule 2 is not exhaustive. Factor 11 covers any drug not listed if it causes steatohepatitis within 30 days of first taking and redevelopment on rechallenge. This requires the person to have been rechallenged with the same drug and to have had a recurrence, which is rare and often clinically contraindicated. That factor will be nearly impossible to prove except in controlled medical settings.

Tenth, terminal events (e.g., pneumonia) are listed as causes of death contributed to by steatohepatitis. But death from pneumonia directly does not necessarily mean the steatohepatitis contributed; the person’s liver disease must have made the pneumonia fatal. The decision-maker will need medical evidence linking the two.

Compliance with this SoP is relevant to two groups: claimants seeking to prove service connection, and decision-makers who must apply the instrument.

For a claimant, the first step is to confirm that their service qualifies as “relevant service” under the SoP: eligible war service (other than operational), defence service (other than hazardous/British nuclear), or peacetime service under the MRCA. If they have operational service, they cannot use this SoP and must check for a subsection 196B(2) SoP for steatohepatitis or rely on general medical evidence. The DVA can advise on service type.

Second, the claimant must obtain a medical diagnosis of steatohepatitis consistent with the definition: fatty change and inflammation with hepatocyte injury, diagnosed by liver biopsy or imaging with biochemical correlation. The diagnosis must exclude the four excluded diseases (alpha-1 antitrypsin deficiency, biliary obstruction, haemochromatosis, Wilson’s disease). If the medical report does not explicitly rule these out, the decision-maker may reject the claim.

Third, the claimant must identify which factor in section 9 applies and gather evidence to prove each element. For the metabolic factors (1,2,6), evidence of the condition must exist at the time of clinical onset. This could include service medical records showing a diabetes diagnosis, BMI or waist circumference measurements, or blood lipid tests. If no contemporaneous records exist, a retrospective opinion from a treating doctor may suffice, but it will be less persuasive.

For alcohol factors (7,8), the claimant must estimate total alcohol intake in kilograms over any five-year period before clinical onset. Medical records may document alcohol use, or the claimant may need to provide a detailed history. The DVA may require corroboration from family or friends. If the claimant cannot produce credible evidence, this factor will fail.

For drug factors (9,10,11), the claimant must prove they took the drug for at least 30 days before onset (or for irinotecan, at least 30 days). For factor 10, the drug must be one listed in Schedule 2 and the claimant must provide medical evidence that it could not be ceased or substituted. A treating specialist’s letter should explain why alternatives were not suitable. For factor 11, evidence of the initial onset within 30 days of starting a drug and recurrence on rechallenge is needed - ideally, medical records documenting both episodes.

For factor 4 (jejunoileal bypass surgery), the claimant must prove the surgery date and that it preceded clinical onset. Medical records should confirm this.

For factor 5 (total parenteral nutrition), the claimant must prove they received TPN for at least 6 continuous months within the year before clinical onset. Hospital records are required.

For factor 3 (rapid weight loss), the claimant must prove a weight loss of at least 20% within six months and that it caused protein-calorie malnutrition. The note gives examples; a dietitian or doctor should confirm the malnutrition.

For factor 12 (inability to obtain appropriate clinical management), the claimant must prove they had steatohepatitis before or during service (but not arising from service), and that service circumstances prevented them from receiving proper treatment, materially contributing to aggravation. This requires evidence of what treatment was appropriate (e.g., specialist referral, medication) and why it was not available (e.g., deployment, lack of resources). This factor is likely to be heavily scrutinised.

Fourth, the claimant must establish the relationship between the factor and service under section 10. If the factor is itself a disease (e.g., diabetes), they may need to prove that disease is service-related using its own SoP. If the factor is a lifestyle condition (e.g., obesity), they must show how service caused or contributed to it - for example, an injury that limited exercise, or service in a location with poor dietary options. Legal advice is essential here.

Fifth, the claimant must lodge a claim with the DVA or the MRCC, providing all supporting evidence. The claim will be assessed by a delegate who applies the SoP. If the claim is refused, the claimant can seek review by the Veterans’ Review Board (VRB) and then the Administrative Appeals Tribunal (AAT). At each stage, the SoP is binding.

For decision-makers, compliance means applying the exact definitions and temporal requirements. They must not extend factors beyond their text. For example, they cannot substitute “overweight” for “obese” (because being overweight is not defined in the instrument). They must require proof that any drug in factor 10 could not be ceased or substituted; if a alternative was available, the factor is not satisfied. They must ensure that the factor related to service - a mere existence of obesity in a veteran is not enough; it must be service-caused.

Decision-makers should also refer to section 11 if the factor involves another disease (e.g., diabetes). They must require the claimant to satisfy the factors in the diabetes SoP before accepting factor 1. This can be time-consuming but is legally required.

The instrument does not prescribe a specific forms or process; compliance is achieved through careful evidence gathering and legal reasoning. Claimants are strongly advised to seek assistance from a DVA advocate, a veterans’ legal service, or a lawyer specialising in military compensation. The cost of non-compliance is a rejected claim.