Statement of Principles concerning subarachnoid haemorrhage (Reasonable Hypothesis) (No. 67 of 2019)

The central concept is "subarachnoid haemorrhage", defined in subsection 7(2) as bleeding into the intracranial subarachnoid space, but excluding extension from a cerebral tumour or intracerebral haemorrhage. This definition is narrower than the general medical class and excludes secondary haemorrhages. The ICD‑10‑AM code I60 or S06.6 is referenced as an identifier but the definition in the instrument governs (s 7(3)). The "reasonable hypothesis" standard is not defined here but is the statutory standard under VEA s 120A and MRCA s 338. The SoP effectively lists the minimum factors that the Authority regards as sufficient to meet that standard. "Relevant service" is defined in Schedule 1 and includes operational, peacekeeping, hazardous, and British nuclear test defence service under the VEA, and warlike and non-warlike service under the MRCA. This is a closed list; service that does not fall within these categories cannot use this SoP. The nineteen factors in section 9 cover a range of aetiological pathways. Physical activity is quantified using METs (metabolic equivalents), defined as a unit of measurement of physical exertion: 1 MET equals 3.5 ml of oxygen/kg of body weight per minute or resting metabolic rate (Schedule 1). The threshold of at least six METs within two hours before onset (s 9(1)) requires activities such as running, heavy lifting, or sustained exertion, not routine walking. Smoking is defined via pack-years: one pack-year equals 20 tailor-made cigarettes per day for one year, or 7,300 cigarettes, with a conversion to weight (7.3 kg of tobacco). The factor requires at least one pack-year before onset, and if smoking has ceased, onset must occur within ten years of cessation (s 9(6)). Alcohol consumption is sex-specific: for males, an average of at least 150 grams per week for a continuous six months; for females, 110 grams per week (s 9(11),(12)). The Australian Standard of ten grams per standard drink is used. Antithrombotic therapy (s 9(7)) is defined broadly in Schedule 1 to include antiplatelet drugs, anticoagulants, and thrombolytic agents, with examples including aspirin, clopidogrel, warfarin, heparin, and newer oral anticoagulants. However, aspirin is also treated separately in s 9(8) as a standalone factor if at least 700 mg is taken within a seven-day period and the last dose is within seven days of onset. Drug use is limited to a specified list of eight substances: amphetamine, cannabis, cocaine, dextroamphetamine, heroin, methamphetamine, phenylpropanolamine, and ecstasy (Schedule 1). The specified list of inflammatory vascular diseases contains nine conditions, including giant cell arteritis, systemic lupus erythematosus, and Behcet disease, each affecting cerebral vessels. "Inability to obtain appropriate clinical management" (s 9(19)) is the only factor that applies only to material contribution or aggravation, not initial onset, and is subject to the limitation in s 10(2) that the subarachnoid haemorrhage must have been suffered before or during (but not arising out of) relevant service.

The instrument directly affects veterans, members of Peacekeeping Forces, and members of the Forces under the VEA, as well as members under the MRCA, who have rendered relevant service. Their dependants are also affected because the SoP covers death from subarachnoid haemorrhage. A person whose service falls outside the definition of "relevant service" in Schedule 1 cannot benefit from this SoP. For example, peacetime service that is not operational, hazardous, or peacekeeping under the VEA, and non-warlike service not under the MRCA, would not be covered. The instrument also affects decision-makers within the Department of Veterans' Affairs and the Military Rehabilitation and Compensation Commission, who must apply the factors when assessing claims. Medical practitioners may need to provide evidence that matches the factor criteria, such as quantifying METs or establishing the exact timing of onset relative to physical activity, smoking cessation, or drug ingestion. The legal representatives of claimants are affected because they must carefully select which factor to rely on and ensure the evidence fits the definitions. The Repatriation Medical Authority itself is the rule-maker, but the instrument constrains its own future determinations by setting a precedent. The SoP indirectly affects the broader community of taxpayers who fund the compensation system, as the existence of a standardised list of factors may either increase or decrease the number of successful claims. The factor "inability to obtain appropriate clinical management" (s 9(19)) particularly affects persons whose subarachnoid haemorrhage already existed before or during service but was not caused by service; they can still claim if the lack of clinical management worsened the condition. This imposes a duty on the Department to consider whether appropriate management was available. The instrument does not affect members of the Australian Defence Force who have no relevant service under the MRCA or VEA, or civilians. It also does not affect claims made under other compensation schemes, such as workers' compensation or motor accident insurance, unless those schemes incorporate the SoP by reference.

The SoP does not impose direct duties on individuals; it sets out conditions under which a claimant has a right to have a reasonable hypothesis accepted. The primary right conferred is that if a person with relevant service satisfies at least one factor in section 9, and that factor is related to service per section 10, then a decision-maker must find that a reasonable hypothesis exists connecting the subarachnoid haemorrhage to service. This is a right to a particular evidentiary conclusion, not a right to compensation itself. The duty on the decision-maker is to apply the SoP strictly according to its terms. The factor in s 9(19) (inability to obtain appropriate clinical management) carries a specific limitation in s 10(2): it applies only to material contribution or aggravation where the subarachnoid haemorrhage was suffered or contracted before or during (but did not arise out of) relevant service. This means if the subarachnoid haemorrhage was caused by service, s 9(19) is not needed because other factors would apply; but if the condition was pre-existing or unrelated, the inability to obtain clinical management can still be linked to service if the absence of proper management worsened the condition. The SoP also gives the decision-maker the duty to consider interplay with other Statements of Principles under section 11. If a factor in s 9 refers to an injury or disease covered by another SoP (e.g., hypertension in s 9(3) or inflammatory vascular disease in s 9(10)), then the factors in that other SoP must be applied. Effectively, the claimant must also satisfy the relevant SoP for that underlying condition to use that factor. For example, to rely on hypertension (s 9(3)), the claimant must show that the hypertension itself is related to service under the SoP for hypertension. This creates a cascading requirement. The claimant has the right to use any of the nineteen factors, but also bears the evidentiary burden of proving the factor exists and is related to service. The SoP does not create a duty on the Repatriation Medical Authority to update the instrument, although it is subject to review. The instrument does not give claimants a right to choose which standard of proof applies; the SoP is for reasonable hypothesis only. Separate SoPs exist for the higher standard of reasonable satisfaction (the "Balance of Probabilities" SoP), but this instrument is explicitly for reasonable hypothesis claims per the heading and the authority under s196B(2).

This instrument itself contains no penalty provisions. It is a legislative instrument that provides evidentiary guidance, not a code of conduct. Enforcement occurs through the claims process: if a claimant or representative submits false evidence to establish a factor, they may be subject to penalties under other legislation, such as the Criminal Code Act 1995 (Cth) for fraud or the VEA itself for making false statements. The SoP does not create any new offences. The practical enforcement of the factor requirements lies with the decision-maker, who must scrutinise the evidence and may deny a claim if a factor is not established. There is no external enforcement body specifically for this instrument. If a decision-maker misapplies the SoP, the claimant can seek review in the Veterans' Review Board or the Administrative Appeals Tribunal, and ultimately the Federal Court. The SoP is binding on decision-makers within the Department and the Commission, so failure to correctly apply it could result in internal administrative consequences. However, the SoP is often the subject of litigation where a veteran argues that a factor should be interpreted broadly or that insufficient weight was given to evidence. The Repatriation Medical Authority itself is not subject to enforcement for the contents of the SoP, as the Authority is a statutory body with discretion over its content. If a factor is too restrictive (e.g., the ten-year smoking cessation window), that is a policy choice, not an enforceable duty. The instrument does not provide for fines, imprisonment, or any punitive measures. Its main effect on compliance is to reduce the discretion of decision-makers, making it harder for them to accept a claim that does not fit the factor criteria. Conversely, it also makes it harder for them to reject a claim that does fit, creating a more rule-bound system. The only "penalty" for a claimant who cannot meet any factor is the denial of the claim. There is no appeal against the SoP itself; it is a disallowable legislative instrument but must be challenged through the Senate disallowance process, not by individual claimants.

The SoP is made under the VEA, specifically subsection 196B(2), and is a legislative instrument binding on persons making decisions under the VEA and the MRCA. It directly interacts with the VEA and MRCA by providing the medical standard for claims under section 120A of the VEA and section 338 of the MRCA. Those sections require that for a claim relating to an injury or disease, the decision-maker must determine whether the injury or disease is related to service; the SoP defines what constitutes a reasonable hypothesis for that purpose. This SoP replaces the 2010 version for subarachnoid haemorrhage, so any claim made after 22 July 2019 must be assessed under the new instrument. The instrument also interacts with other SoPs through section 11. If a factor in section 9 refers to an injury or disease that itself has a SoP (e.g., hypertension, chronic renal failure, traumatic brain injury, inflammatory vascular diseases), then the factors in that other SoP must be applied as in force from time to time. This creates a network of interconnected instruments. For example, to satisfy factor s 9(2) (concussion or moderate to severe traumatic brain injury within 30 days), the claimant must also show that the concussion or TBI is related to service under the SoP for those conditions. Similarly, factor s 9(15) (acquired disorder resulting in impaired haemostasis) would require reference to the SoP for that disorder if one exists. The SoP does not alter the operation of any other Commonwealth laws. It also does not affect state or territory workers' compensation laws, though it may be referenced as medical evidence in those jurisdictions. The definition of subarachnoid haemorrhage uses ICD-10-AM coding (Tenth Edition), which is a classification system used in Australian hospitals; this ensures consistency with medical records. The instrument does not interact with criminal law, privacy law, or contract law. It is part of the broader veterans' compensation framework which also includes provisions about standard of proof, onus of proof, and time limits for claims. The SoP does not incorporate international instruments. One notable interaction is with the concept of "terminal event" defined in Schedule 1: if a person dies from pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function contributed to by subarachnoid haemorrhage, the death is considered death from subarachnoid haemorrhage for the purposes of the SoP. This links the SoP to the definition of death in other legislation such as the VEA s 5D (disease or injury causing death). There is no conflict with the Human Rights Act or similar; the SoP is purely technical.

The instrument notes in section 4 that it repeals the earlier "Statement of Principles concerning subarachnoid haemorrhage No. 67 of 2010" (F2010L02306). That is the only direct amendment history recorded in the source. The 2010 instrument was itself made under subsection 196B(2) of the VEA and was replaced because the Repatriation Medical Authority reviewed the medical-scientific evidence and determined that a new SoP was warranted. The current instrument is dated 21 June 2019 and commenced on 22 July 2019. It has not been amended since commencement, based on the source provided. There is no indication of any subsequent amending instruments. The SoP may be amended in the future as medical evidence evolves or as the Authority conducts its five-yearly review cycle. The instrument itself is a complete replacement rather than an amendment to the 2010 version. Users should check the Federal Register of Legislation for any amending instruments after 2019. The instrument also contains a note that the specified list of drugs and other definitions are as at the date of making. Any future amendment would likely involve updating the definitions (e.g., adding new drugs) or adding factors. The instrument does not contain transitional provisions, so any claim made after 22 July 2019 must use the new factors, even if the subarachnoid haemorrhage occurred before that date. Claims made before that date but not yet decided would have been subject to the 2010 SoP unless the new instrument applies retrospectively (it does not say it does). The repeal clause (s 4) is straightforward: the old instrument ceases to have effect on commencement. No amendment history is provided for the 2010 instrument itself; it was likely the original SoP for subarachnoid haemorrhage.

The source document does not contain any references to litigation. No cases are cited in the instrument itself. Statement of Principles are frequently challenged in the Administrative Appeals Tribunal and the Federal Court, but this specific instrument has not been tested in litigation, at least not recorded in the instrument. The Repatriation Medical Authority's factors are often the subject of dispute, especially regarding interpretation of phrases like "clinical onset", "at the time of", and "within two hours". However, without case citations from the source, we cannot name any cases. It is possible that the previous 2010 SoP was litigated, but that is not in this document. The Authority itself notes in section 8 that there is "sound medical-scientific evidence" that indicates the condition can be related to service, which is a conclusion that could be challenged in proceedings. In practice, litigation over SoPs often centres on whether a factor exists on the facts (e.g., whether a certain activity reached six METs, whether hypertension was present at the relevant time). The High Court has considered the overarching framework of SoPs in cases such as Repatriation Commission v Gorton (2001) and Repatriation Commission v Deledio (1998), but those are not mentioned in the instrument. The existence of a reasonable hypothesis SoP does not guarantee success for a claimant; it merely raises the hypothesis. The decision-maker must then determine whether the hypothesis is reasonable under the law. The SoP can be used to support a claim, but a respondent may argue that the factor has not been proven. The instrument's definitions, such as the precise timing requirements and the closed lists, are common sources of argument. For example, whether a drug not on the specified list can still be considered via another factor. The instrument is likely to be cited in any future litigation about subarachnoid haemorrhage claims.

Several provisions in this SoP are traps for the unwary. First, the definition of subarachnoid haemorrhage in s 7(2) explicitly excludes extension from a cerebral tumour or from an intracerebral haemorrhage. If a veteran has subarachnoid bleeding secondary to a known tumour, the claim does not fall under this SoP. The factor may need to be considered under the SoP for the underlying tumour instead. Second, the smoking factor (s 9(6)) requires that if smoking has ceased, the clinical onset must occur within ten years of cessation. A veteran who stopped smoking more than ten years before onset cannot use this factor, even if the total pack-year history is high. Third, the physical activity factor (s 9(1)) requires activity of at least six METs within two hours before clinical onset. Ordinary walking may not meet this threshold; the definition of MET includes resting metabolic rate, so six METs equates to about six times the resting energy expenditure. This is heavy exertion such as shovelling, running, or carrying heavy loads. The claimant must also demonstrate that the activity occurred within a two-hour window before the bleed, which may be difficult to prove if the exact time of onset is unclear. Fourth, the alcohol factors (s 9(11),(12)) require a continuous period of at least six months of average consumption at the specified level. Binge drinking or recent onset of heavy drinking will not satisfy the factor. Fifth, the drug use factor (s 9(13)) is limited to the specified list of eight drugs. Use of other drugs, such as prescription opioids or benzodiazepines, is not covered, even if they might be relevant aetiologically. Sixth, the antithrombotic therapy factor (s 9(7)) requires therapy within two weeks before onset, and includes many drugs, but note that aspirin is also covered separately in s 9(8) with a different threshold (700 mg in seven days). Using both factors may be possible but the evidence requirements differ. Seventh, the factor for "inability to obtain appropriate clinical management" (s 9(19)) only applies to material contribution or aggravation, not original onset, and only where the subarachnoid haemorrhage was suffered before or during service but did not arise out of service (s 10(2)). This is a narrow carve-out. Eighth, the factor for pregnancy-induced hypertension (s 9(4)) is separate from general hypertension (s 9(3)). If a woman develops hypertension during pregnancy that leads to SAH, she must rely on s 9(4) rather than s 9(3). Ninth, the factor for childbirth or postpartum (s 9(5)) only covers up to six weeks postpartum. After six weeks, the factor does not apply. Tenth, the definition of chronic renal failure (Schedule 1) requires a glomerular filtration rate of less than 15 mL/min/1.73 m² for at least three months, or a need for renal replacement therapy. Lesser degrees of kidney failure do not qualify. Eleventh, the instrument uses the concept of "clinical onset" without defining it. This can be contested in borderline cases. Twelfth, section 11 means that if you rely on a factor that is itself a disease with its own SoP (e.g., hypertension), you must also meet that SoP. This multiplies the evidentiary burden. Thirteenth, the instrument applies to claims under both VEA and MRCA, but the definitions of relevant service differ slightly between the two acts; ensure the service classification is correct. Fourteenth, the instrument does not apply to claims where the standard of proof is reasonable satisfaction (balance of probabilities); a separate SoP exists for that.

For a claimant seeking to use this SoP in a compensation claim, compliance means establishing at least one factor from section 9 and showing that the factor is related to the person's relevant service. The first step is to obtain a medical diagnosis that confirms subarachnoid haemorrhage as defined: bleeding into the intracranial subarachnoid space, not secondary to tumour or intracerebral haemorrhage. The diagnosis should ideally include neuroimaging evidence. The clinical onset date must be fixed. The claimant then identifies which factor(s) apply. For each factor, the evidence must match the precise wording. For factor (1) (physical activity), obtain witness statements or service records showing that the person undertook activity of at least six METs within two hours of the onset. Common examples during military service include combat drills, heavy lifting, or running obstacle courses. A MET chart may be used to estimate the exertion level. For factor (2) (concussion or moderate to severe TBI within 30 days), medical records of the head injury are needed, with classification of severity. For factor (3) (hypertension at the time), blood pressure readings from before or at the time of the bleed, and evidence linking the hypertension to service (e.g., stress of service, secondary to other conditions). For smoking (6), calculate pack-years precisely: number of cigarettes per day divided by 20, multiplied by years. If smoking ceased, ensure the clinical onset is within ten years. Provide service records that show smoking during service, or that smoking was related to service (e.g., smoking as a coping mechanism). For alcohol (11,12), obtain medical or self-report evidence of average weekly intake over six months, converted to standard drinks. Corroborating evidence such as service medical records mentioning alcohol misuse strengthens the claim. For drug use (13), a drug test or medical record indicating use of a specified drug within 72 hours before onset is required. The drug must be on the list; for example, cocaine but not LSD. For antithrombotic therapy (7), a prescription history or medication chart showing the drug and timing. For aspirin (8), show that at least 700 mg was taken in a seven-day period and the last dose no more than seven days before onset. Over-the-counter aspirin use must be documented. For pregnancy and postpartum factors (4,5), obstetric records are essential. For inflammatory vascular disease (10), a confirmed diagnosis of one of the nine listed conditions, with evidence that it affected cerebral vessels. For acquired haemostasis disorder (15), laboratory results showing coagulopathy. For chronic renal failure (18), GFR results or evidence of dialysis. For menopausal status (17), medical confirmation. For inability to obtain clinical management (19), evidence that the person was not provided appropriate treatment for subarachnoid haemorrhage (e.g., delay in hospital transfer, lack of neurosurgery) and that this worsened the outcome. Note the limitation in s 10(2). All evidence must be related to service per s 10. For a peacetime veteran, the factor must have been caused or contributed to by service, or the person's service must have involved the activity or exposure. The Department should be provided with a detailed statement and supporting documents. If a factor underlying the SAH (e.g., hypertension) has its own SoP, the claimant must also meet that SoP. For decision-makers, compliance means strictly applying the factors, using the defined terms, and rejecting claims that do not meet the criteria even if there is other medical opinion that causation is plausible. The instrument is designed to limit discretion.