Statement of Principles concerning tinea (Balance of Probabilities) (No. 56 of 2024)

The central concept is "tinea" as defined in subsection 7(2). It is a fungal infection caused by a closed list of dermatophyte genera. The definition is exhaustive: if the causative organism is not one of the named genera, the condition is not tinea for the purposes of this SoP, even if clinically labelled as tinea. The exclusion of tinea versicolour (caused by Malassezia, a yeast) and tinea nigra (caused by Hortaea werneckii) reflects the medical distinction. The instrument includes tinea gladiatorum (a form of tinea corporis associated with contact sports) and Majocchi's granuloma (deep invasive folliculitis). Note 1 to subsection 7(2) explains that tinea includes Id reactions (allergic rash from distant tinea). Note 2 is critical: the SoP must be invoked separately for each instance of tinea, in each separate location of the body, and in each instance separate in time. This prevents claimants from aggregating multiple episodes or sites under a single factor analysis. It imposes a significant burden: a veteran with tinea pedis and tinea cruris must satisfy the factor test for each location independently.

"Clinical onset" and "clinical worsening" are key temporal concepts, though not separately defined in the dictionary. Section 9 uses "clinical onset" for factor 1 (exposure) and "clinical worsening" for factors 2 through 11. The note to factor 3 gives examples of clinical worsening: dissemination, deep invasion (Majocchi's granuloma), or becoming refractory to first-line treatment. The timing window for factor 1 is between 2 days and 3 weeks before clinical onset or clinical worsening. This is the incubation period for dermatophyte infections; outside that window, the factor cannot satisfy the connection. For the other factors (e.g., diabetes, immunosuppression), they must exist "at the time of clinical worsening". For factor 2 (skin maceration), the maceration must occur between 2 days and 3 weeks before clinical worsening.

"Relevant service" is defined in the dictionary and is narrower than the full range of service recognised under the VEA. It excludes operational service (which is covered by a reasonable hypothesis SoP) and hazardous service and British nuclear test defence service under the VEA, and warlike/non-warlike service under the MRCA. This means that a veteran who served in a combat zone or on hazardous duties cannot use this SoP; they must rely on the reasonable hypothesis counterpart. The "balance of probabilities" standard itself is a concept imported from the VEA and MRCA. Under section 120B of the VEA, for claims relating to eligible war service (non-operational) or defence service, the commission must be satisfied on the balance of probabilities that the injury/disease is connected to service, applying the relevant SoP. This is a higher evidentiary threshold than "reasonable hypothesis" (which requires only that the hypothesis is not disproved). The SoP does not create a presumption; it provides a set of factors that, if established and related to service, allow the decision-maker to be satisfied of connection. If none of the factors exist, the claim must fail under this SoP (unless another SoP applies via section 11).

"Skin maceration" is defined as softening of the skin by soaking in aqueous liquids or sweat. "Terminal event" lists five causes of death. Note that death from tinea is included only if tinea contributed to a terminal event; a direct death from tinea itself (e.g., from sepsis) may also qualify, but the definition uses "contributed to" rather than "caused". The instrument also defines MRCA and VEA.

The SoP directly affects veterans, members of the Australian Defence Force, and their dependants who claim compensation for tinea or death from tinea under the VEA or MRCA. However, it only applies to those whose service falls within the definition of "relevant service": eligible war service (non-operational), defence service (non-hazardous, non-British nuclear test), and peacetime service under the MRCA. This excludes the majority of active combat veterans and those who served in hazardous environments (e.g., nuclear test veterans). For such excluded groups, the separate reasonable hypothesis SoP applies, which has different factors and a lower evidentiary standard. The SoP also affects legal practitioners, advocates, and departmental decision-makers who must apply it to claims.

The instrument also affects medical practitioners who provide evidence for claims. They must understand the precise definition of tinea and the closed list of dermatophytes, the exclusions, and the timing requirements. The factor list requires evidence of conditions such as diabetes mellitus, HIV infection, chronic renal failure, peripheral artery disease, chronic venous insufficiency, and varicose veins. These are not trivial to diagnose and document over a veteran's service history. The factor "inability to obtain appropriate clinical management" (factor 11) potentially affects rural and remote veterans, those with service-related barriers to accessing healthcare, and those whose tinea worsened because of delays in treatment that can be connected to service. However, that factor requires a causal link: the inability to obtain appropriate clinical management must itself be related to service, and the clinical worsening must occur before appropriate management was obtained.

The SoP affects the Repatriation Medical Authority itself as the determiner of the principles. The RMA's view that it is more probable than not that tinea can be related to service (section 8) reflects its assessment of the medical evidence. This view is not binding on the merits of individual claims, but it shapes the factor list. The instrument also affects the Commonwealth's financial liability. Tinea is generally a minor, self-limiting condition, but claims for death from tinea could involve significant payouts. The narrow factor list (11 items, many highly specific) limits the number of successful claims compared to a broader list. For example, the inclusion of chronic renal failure only for tinea unguium, and peripheral artery disease only for tinea of the foot, means that systemic conditions must be matched to specific locations, reducing the scope.

The repeal of the 2015 SoP affects anyone with a pending claim under the old instrument. If a claim was lodged before 23 July 2024 but not yet determined, the transitional provisions of the VEA apply. Generally, a claim is assessed under the law in force at the time of determination, not the time of lodgement, unless the VEA says otherwise. The SoP does not address transitional arrangements; it simply states it applies to claims under those sections. Therefore, claimants and advocates must be alert to the change.

The Repatriation Medical Authority has a duty under section 196B(3) of the VEA to determine Statements of Principles on the balance of probabilities for non-operational service. It has exercised that duty here. The Authority must base its determination on "sound medical-scientific evidence", which it purports to have done (section 8). The duty is procedural: it must follow the Act, consider the evidence, and publish the instrument. There is no right of appeal against the SoP itself; it is a legislative instrument that can be disallowed by Parliament, but that is a political check.

Claimants have a right to rely on the SoP to establish connection between tinea and service. Under section 120B of the VEA, a decision-maker must be satisfied on the balance of probabilities that the injury or disease is connected to service, and in doing so must apply the relevant SoP. If a claimant can establish at least one factor in section 9 and show that the factor is related to their relevant service, then (subject to section 10) the connection is established. This imposes a duty on decision-makers to accept the connection if the factor is proven; they cannot reject the claim on the basis that tinea is generally not related to service. However, the decision-maker retains discretion to assess whether the factor is causally related to service. For example, factor 1 requires unprotected physical contact with infected persons, animals, or contaminated surfaces. The claimant must show that contact occurred during service (or as a result of service) and that the timing fits.

Section 10(1) states that the factor must be "related to the relevant service rendered by the person". This is a separate requirement: it is not enough that tinea exists and a factor exists; the factor itself must have a causal connection to service. For factor 1, if a veteran contracted tinea from using a communal shower during peacetime service, that shower use is part of service. But if a veteran contracted tinea from a pet at home while on leave, the factor (unprotected contact with an infected animal) exists but is not related to service. Section 10(2) adds a limitation for clinical worsening: the factors in section 9 that refer to clinical worsening apply only to material contribution or aggravation of tinea where the tinea was suffered or contracted before or during (but did not arise out of) relevant service. This is a complex rule: if a veteran had tinea before service (or contracted it during service but not from service), and it worsened during service due to a factor, then the worsening is connected only if the factor materially contributed or aggravated. The SoP does not define "material contribution", but case law from the AAT and courts would apply.

Section 11 provides that if a factor refers to an injury or disease for which another SoP exists under subsection 196B(3), then the factors in that other SoP apply. This cross-reference mechanism avoids duplication. For example, if the factor "diabetes mellitus" appears (factor 3), and the RMA has determined a SoP for diabetes mellitus, the claimant may need to satisfy the diabetes SoP if the diabetes itself is in issue. But careful reading: section 11 says "if a factor referred to in section 9 applies in relation to a person; and that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA; then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time." This seems to mean that if the factor is itself a disease with its own SoP, the decision-maker must apply that SoP to determine whether the factor exists. This is a drafting nuance that could lead to circularity: to prove the factor (diabetes), the claimant must first satisfy the diabetes SoP, which may require its own connection to service. This potentially raises the barrier further.

This instrument does not create any penalties. It is a legislative instrument that sets standards for decision-making under the VEA and MRCA. Enforcement mechanisms arise from those Acts, not from this SoP. If a claimant makes a false statement or provides false evidence to establish a factor, they may face penalties under the Criminal Code (Cth) or specific provisions in the VEA relating to fraud. Section 219 of the VEA creates offences for obtaining payment by false pretenses. The SoP itself is not enforceable against anyone; it is simply the criterion that decision-makers must apply.

The primary enforcement of the SoP's application is through the review processes. A decision made under section 120B of the VEA that applies this SoP can be reviewed by the Veterans' Review Board (VRB) and then by the Administrative Appeals Tribunal (AAT). If the decision-maker misapplies the SoP (e.g., misinterprets "clinical worsening" or ignores a factor), the VRB or AAT can set aside the decision. The SoP is binding, but its interpretation is subject to judicial review. The AAT may consider the meaning of terms like "unprotected physical contact" or "inability to obtain appropriate clinical management". There is no penalty for the decision-maker who errs, but the veteran may receive an adverse decision.

The RMA itself has no enforcement role once the SoP is determined. The Ombudsman or the Senate could inquire into the SoP, but that is oversight, not enforcement. The SoP includes a repeal provision (section 4) which ensures the old instrument is no longer in force, preventing dual or conflicting applications.

In practical terms, the enforcement risk for claimants is that a claim may be rejected if they fail to prove a factor on the balance of probabilities. The SoP sets a high bar by requiring specific timing, specific location, and specific service relationship. For example, proving "skin maceration at the affected site between 2 days and 3 weeks before the clinical worsening" requires medical records documenting maceration and the timing of worsening. In the absence of contemporaneous records, the claimant may struggle. The enforcement of the SoP against the department is also possible through legal challenge; if the department refuses to apply the SoP to a claim that clearly meets a factor, the claimant can seek review and the tribunal can enforce compliance.

The SoP is a delegation of the VEA. Section 196B(3) of the VEA empowers the RMA to determine SoPs for the purposes of claims under section 120B (non-operational service). The MRCA is cross-referenced: section 339 of the MRCA requires application of SoPs for peacetime service. The SoP applies to claims under both Acts, as stated in section 5. However, the definitions of "relevant service" in the SoP dictionary are specific to each Act: paragraphs (a) and (b) refer to VEA service types, and paragraph (c) refers to peacetime service under MRCA. This means that if a person has service under both Acts (e.g., peacetime and hazardous service), the SoP applies only to the peacetime component; for the hazardous component, the reasonable hypothesis SoP applies.

Section 11 creates an interaction with other SoPs. If a factor in section 9 refers to an injury or disease for which a SoP exists under subsection 196B(3), then the factors in that other SoP apply. For example, factor 3 is "having diabetes mellitus at the time of clinical worsening". If there is a SoP for diabetes mellitus under subsection 196B(3) (which there is, No. 95 of 2023 or similar), then to establish "having diabetes mellitus" the claimant must satisfy the diabetes SoP. This means the claimant must prove that the diabetes itself is connected to service (on balance of probabilities) or that it meets the factors in that SoP. If the diabetes is not service-related, the factor 3 cannot be established, even if the diabetes is medically present. This is a significant interaction: it turns a simple medical condition into a service connection issue. The same could apply to chronic renal failure (factor 6), peripheral artery disease (factor 8), chronic venous insufficiency (factor 9), and varicose veins (factor 10). The SoP for those conditions may have their own factor lists, adding layers of proof.

The SoP interacts with the VEA definition of "disease" and "injury". Tinea is a disease. The SoP covers both tinea and death from tinea. If a veteran dies from causes contributed to by tinea, the claim for dependant's benefits will be assessed under this SoP (if relevant service) or the reasonable hypothesis SoP (if operational service). The SoP does not interact with workers' compensation laws or tort law; it is solely within the veterans' compensation framework.

The repeal of the 2015 SoP means that previous interpretations of that instrument are no longer directly applicable. However, the dictionary definitions in the new SoP may differ. For instance, the definition of tinea in the 2015 SoP may have excluded certain conditions that are now included (e.g., Majocchi's granuloma was included in previous SoPs? Not stated in source). The new SoP includes a list of dermatophyte genera that includes Guarromyces and Paraphyton, which may be additions. There is also a new factor specific to risankizumab and guselkumab (biologic drugs), reflecting updated medical evidence. The interaction with state and territory health regulations is irrelevant; the SoP only applies to Commonwealth compensation laws.

The instrument also interacts with the common law principle of causation. The SoP provides a statutory shortcut: if a factor exists and is service-related, connection is established. But the SoP does not override the requirement that the factor must be related to service. That remains a question of fact and degree.

This instrument is a replacement of SoP No. 12 of 2015. It is not an amendment but a repeal and remake. Section 4 expressly repeals the 2015 instrument. The commencement date is 23 July 2024. There is no amendment history within the instrument itself; it is the first version of this SoP under the current numbering. It is part of a series: there are also SoP No. 55 of 2024 for tinea (reasonable hypothesis) and No. 56 of 2024 for tinea (balance of probabilities). The RMA regularly reviews SoPs; the previous one (2015) had been in force for about nine years. The 2024 version reflects updated medical evidence and changes in classification (e.g., ICD-10-AM edition, inclusion of new drugs).

Changes from the 2015 SoP can be inferred by comparing the factor list. The 2015 SoP (not provided) may have had different factors, different definitions of tinea, and different timing windows. The new SoP explicitly adds factors for risankizumab and guselkumab (factor 7), peripheral artery disease (factor 8), chronic venous insufficiency (factor 9), and varicose veins (factor 10). It also adds "skin maceration" as a defined term and includes "Guarromyces" and "Paraphyton" in the list of dermatophytes. The previous SoP may not have included those. The note about Id reactions is new. The instrument also includes a note about clinical worsening examples (dissemination, deep invasion, refractory to treatment), which may have been absent before. The ICD-10-AM edition is now the Tenth Edition (2017) rather than an earlier edition.

There is no other amendment history before or after this instrument. It is a standalone determination. Future amendments could occur if the RMA revises it again. The RMA typically reviews SoPs every few years, but there is no set schedule.

The source document contains no references to litigation. No cases are named. The determination itself is not a court decision. However, the previous SoP (No. 12 of 2015) may have been the subject of litigation in the AAT and federal courts. Common issues in tinea SoP litigation include the interpretation of "clinical onset" versus "clinical worsening", the meaning of "unprotected physical contact", the timing windows, and the relationship to service. The balance of probabilities standard also generates litigation over the standard of proof. But because this instrument is new, there is no litigation history specific to it. We can only note that decisions interpreting this SoP will likely emerge in the future.

The VEA has a body of case law on the application of SoPs generally. The AAT has held that SoPs are to be applied strictly but not inflexibly. The Federal Court has considered the validity of SoPs, including challenges based on natural justice and the adequacy of the RMA's reasoning. However, the RMA's determination is protected from review on the merits; it can only be challenged on jurisdictional grounds.

It is worth noting that tinea claims are relatively uncommon in the AAT compared to more serious conditions. Most claims are likely resolved at initial decision or VRB level. The specific factors added for biologic drugs and maceration may lead to interpretative issues if claimants attempt to stretch definitions.

Several traps exist for the unwary. First, the SoP applies only to "relevant service" as defined. Claimants with operational service or hazardous service cannot use this SoP; they must use the reasonable hypothesis SoP. If a practitioner applies this SoP to an operational service claim, the decision must be set aside. The distinction turns on the type of service, not the severity of the condition.

Second, the definition of tinea excludes some common skin infections mislabelled as tinea, such as tinea versicolour and tinea nigra. A diagnosis of "tinea" on a medical certificate may not satisfy the definition if the causative organism is not a listed dermatophyte. The clinical must specify the organism or the diagnosis must be consistent with the SoP definition. Note 2 to subsection 7(2) requires the SoP to be invoked separately for each instance and location. This means a person with tinea on both feet and the groin must establish three separate sets of factors, each with its own timing and causation analysis. This can dramatically increase the evidentiary burden.

Third, the timing window for factor 1 (exposure) is "between 2 days and 3 weeks before the clinical onset or clinical worsening". This is a narrow window. If the exposure occurred more than 3 weeks before onset, or less than 2 days, the factor cannot be used. Many veterans may not remember exact exposure dates. The note gives examples of exposures (contact sports, unarmed combat, animals, communal facilities). But proving the exact date of exposure for self-limited contact is difficult.

Fourth, several factors require a pre-existing condition (diabetes, HIV, chronic renal failure, etc.) to be present "at the time of clinical worsening". If the claimant's tinea worsened before they were diagnosed with diabetes, the factor may not apply unless they can prove the diabetes was subclinical but present. Medical evidence must show the condition existed at that precise time.

Fifth, the factor "inability to obtain appropriate clinical management" (factor 11) is deceptively broad. It does not require that the inability was caused by service; it only requires that the inability existed and the tinea clinically worsened before appropriate management was obtained. However, the factor itself must be related to service under section 10(1). So the claimant must show that service caused or contributed to the inability to obtain clinical management. For example, being posted to a remote area with no pharmacy may qualify. But if the veteran simply chose not to see a doctor, that inability is not service-related. The term "appropriate clinical management" is not defined; it may include topical antifungals, oral medications, or specialist referral. The clinical worsening must occur before management is obtained. This factor could be used in cases where the veteran's service delayed treatment, leading to worsening of a pre-existing or service-acquired tinea.

Sixth, section 10(2) severely limits the clinical worsening factors. They apply only to a person whose tinea was "suffered or contracted before or during (but did not arise out of) the person's relevant service". This means if the tinea first arose out of service (e.g., contracted during service from a contaminated shower), then the worsening factors in section 9(2)-(11) cannot be used to claim that the worsening is connected. The initial tinea is already connected under the onset factor; the worsening is automatically connected if the initial condition is connected. The clinical worsening factors are a backup for those whose tinea pre-existed service or arose during service but not from service. This is a complex condition that may catch practitioners.

Seventh, the definition of "terminal event" includes "cessation of brain function", which may overlap with brain death. But the tinea must have contributed to that event. For a superficial skin infection to contribute to brain death is rare; it would require a severe systemic complication like sepsis. The note says death from tinea includes such cases, but the evidentiary bar is high.

Eighth, the cross-reference in section 11 means that some factors may require the claimant to satisfy other SoPs. For instance, to prove diabetes mellitus (factor 3), the claimant must meet the diabetes SoP, which may itself require a service connection. This creates a cascade of proofs.

For a claimant seeking to rely on this SoP, compliance means establishing at least one factor in section 9 and demonstrating that the factor is related to relevant service. The first step is to identify the type of service. If the service is operational, hazardous, or British nuclear test defence service, this SoP is not applicable; the practitioner should locate the reasonable hypothesis SoP for tinea (No. 55 of 2024). If the service is eligible war service (non-operational), defence service (non-hazardous), or peacetime service under MRCA, this SoP applies.

Next, clearly diagnose tinea according to the definition. Obtain a dermatologist or GP report confirming the infection is caused by a listed dermatophyte. Exclude tinea versicolour, tinea nigra, etc. If the diagnosis is not specific, request a fungal culture or microscopy. Identify the exact location(s) and date(s) of clinical onset. Remember Note 2: each location is a separate claim. If the tinea is recurrent, each recurrence may be a separate instance.

Then, scan the factor list. Factor 1 (exposure) is the most common. The claimant must provide evidence of unprotected physical contact with an infected person, animal, contaminated object, communal shower, soil, or self-inoculation. The contact must occur between 2 days and 3 weeks before onset or worsening. Documentary evidence may include service records showing deployment to areas with communal bathing, unit training involving contact sports, or medical records showing other personnel with tinea. For animal contact, record exposure to pets or working dogs.

If the claimant cannot prove exposure, consider other factors. Skin maceration (factor 2) requires evidence of softening from prolonged moisture, such as from wearing wet boots for days. Medical records of trench foot or macerated skin may suffice. Timing again is critical: maceration must be 2 days to 3 weeks before worsening.

Medical conditions such as diabetes, HIV, renal failure, etc., require clinical documentation. The factor must be present at the time of worsening. For chronic renal failure, the specific criterion (GFR <15 for 3 months or dialysis) applies only for tinea unguium. For peripheral artery disease, chronic venous insufficiency, varicose veins, the factor is limited to specific sites. For the biologic drugs risankizumab and guselkumab, the claimant must be taking them at the time of worsening.

Factor 11 (inability to obtain appropriate clinical management) is a catch-all. The claimant must show that clinical management was not available or accessible due to circumstances of service, and that tinea worsened before obtaining it. This could be proven by service records showing remote postings, lack of medical facilities, or operational demands that prevented treatment. The "inability" must be service-related.

For each factor, the claimant must also prove the factor is related to relevant service under section 10(1). This is a separate causal link. For example, if a veteran develops diabetes during service, the diabetes itself must be related to service (which may require its own SoP). The factor list does not circumvent the need for service connection of the factor itself.

Practitioners should note the transitional effect: claims lodged before 23 July 2024 but not yet determined will still be assessed under the 2015 SoP? The VEA provides that the law in force at the time of determination applies, unless the Act provides otherwise. It is safer to assume the new SoP applies to all decisions made after 23 July 2024, even if the claim was lodged earlier. The SoP itself says it "applies to a claim to which section 120B of the VEA or section 339 of the MRCA applies" without date restriction. So if the decision is made after the commencement date, the new SoP governs.

For decision-makers, compliance means applying the SoP strictly. Do not rely on clinical judgment unguided by the factors. If a claimant cannot establish any factor in section 9, the claim must be refused. If a factor is established, verify that it is related to service. Do not infer relationships; require direct evidence. Pay attention to the type of service and the exclusion of operational/hazardous service. If the wrong SoP is applied, the decision may be overturned on review.

Finally, maintain clear records of all medical evidence and service history. The SoP is detailed but its application depends on the quality of evidence. Claimants should work with an advocate experienced in veterans' law to ensure that the documentation meets the strict requirements of timing, location, and service connection.