Statement of Principles concerning transverse myelitis (Balance of Probabilities) (No. 72 of 2021)

The Statement organises its legal-medical rules around a small number of interlocking concepts: the definition of the disease that the Statement covers, the standard of causation, a closed list of qualifying factors, the linkage requirement to relevant service, and cross-reference to other Statements. Each of those is defined or operationalised in statute text.

Definition of transverse myelitis: The instrument defines transverse myelitis as an acute or subacute immune-mediated inflammatory disorder of the spinal cord producing impaired motor, sensory or autonomic function (s 6(2)(a)). The definition explicitly excludes a list of alternative causes or overlapping diagnoses: acute disseminated encephalomyelitis, atopic myelitis, intrathecal chemotherapy, multiple sclerosis, neuromyelitis optica syndrome, radiation, spinal cord compression, trauma, tumour invasion, and vascular, metabolic or degenerative pathologies (s 6(2)(b)). The instrument notes typical clinical presentation and that diagnosis can be confirmed by spinal cord inflammation on neuroimaging or cerebrospinal fluid analysis (s 6 note 1 and note 2). Although it notes an ICD‑10‑AM code (G37.3) commonly used for TM, it stresses the statutory meaning of TM is the clinical definition in s 6(2) rather than coding alone (s 6(3)-(4)).

Standard of causation: The RMA states the basis for its factors is that “on the sound medical‑scientific evidence available” it is more probable than not that TM and death from TM can be related to relevant service (s 7). The Statement therefore operates at the balance of probabilities standard.

Factors that must exist: Section 8 lists the discrete medical/epidemiological factors. The instrument requires at least one of those factors to be present before TM or death from TM can be said, on the balance of probabilities, to be connected to service (s 8 opening). Timing windows are explicit in multiple items (two months before clinical onset for several factors) and absent in others (transplant, inability to obtain appropriate clinical management) (s 8(1)-(9)).

Relationship to service: The Statement does not stop at the presence of a factor; s 9(1) requires the factor to be related to the person’s relevant service. The Schedule defines “relevant service” to include eligible war service (other than operational service), defence service (other than hazardous and British nuclear test defence service) under the VEA, or peacetime service under the MRCA (Schedule 1).

Death and terminal events: The Statement treats death from TM as included where the TM “contributed to” a terminal event or condition, with “terminal event” defined in the Schedule to include pneumonia, respiratory failure, cardiac arrest, circulatory failure or cessation of brain function (s 6(5); Schedule 1).

Cross-Statements: If a listed factor refers to another injury or disease that itself has an RMA Statement, s 10 makes those factors in the other Statement apply in accordance with that Statement’s terms.

Definitions and lists: The Schedule supplies key definitional scaffolding. “Specified list of drugs” is defined as biologic agents for cancer or tumour necrosis factor-α inhibitors (Schedule 1). Biologic agent is itself defined and examples are given in a note (tyrosine kinase inhibitors, immune checkpoint inhibitors, dinutuximab).

Operationally, the Statement therefore links specific, time‑delimited medical events or diagnoses to TM, then requires an evidentiary link between the factor and the person’s service. It does not create independent entitlements or set payment levels; it is a medical-legal instrument to be applied by decision-makers in the VEA/MRCA claims process (s 4, s 3).

Primary subjects: The Statement explicitly applies to claims to which section 120B of the VEA or section 339 of the MRCA apply (s 4). That makes its direct effect confined to applicants pursuing those statutory claim pathways: veterans and members of the Forces whose claims for TM or death from TM are assessed under those provisions. The Schedule’s definition of “relevant service” narrows the pool further: the instrument is directed at persons whose service is eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service) under the VEA, or peacetime service under the MRCA (Schedule 1).

Decision-makers and administrators: The RMA itself made the Statement under s 196B(3) of the VEA (s 3). The Statement is intended to be applied by those charged with determining VEA and MRCA claims; while the instrument does not name the decision-maker in each individual claim, its legal effect is to provide the evidentiary/causation parameters decision-makers must use when assessing whether TM is connected with relevant service (s 4). Administrators and medico-legal assessors in the claims process will therefore be the users of this instrument.

Medical practitioners and treating clinicians: The Statement creates concrete evidentiary demands that affect clinicians who provide medical records, imaging reports, CSF analysis, immunology or oncology records, transplant histories and vaccination records. The diagnostic notes in s 6(2) and note 2 specifically identify neuroimaging and CSF analysis as clinical evidence that confirms TM.

Laboratories and hospitals: Because several factors require microbiological or immunological evidence (infection with identified organisms; presence of systemic autoimmune disease; evidence of malignancy), laboratories and hospitals that hold diagnostic records will be sources of the evidence claimants must produce.

Families and estates in death claims: For claims involving death from TM, the Statement treats death as included where TM “contributed to” the terminal event (s 6(5)), and the Schedule defines terminal events. Estates or family members lodging death-related claims must gather cause-of-death and terminal event documentation.

Third-party stakeholders: Where a factor refers to another disease or condition that itself is covered by a separate RMA Statement, s 10 requires those other Statements to be taken into account. That creates interdependencies across Statements and requires claimants and decision-makers to consult multiple RMA instruments where appropriate.

Who bears costs and evidentiary burdens: The instrument does not specify payment of costs. Practically, claimants will bear direct costs of obtaining medical evidence and expert reports needed to demonstrate the presence of a factor and its relationship to service. Administrative bodies will bear costs of applying the Statement in adjudications. The instrument itself does not create a fee or penalty regime (no penalties specified).

Geographical and temporal scope: The Statement’s legal application starts from its commencement date (21 June 2021) (s 2) and applies to claims under the statutory provisions cited in s 4. It is not expressed to be retrospective or prospective beyond its application to claims under those statutory provisions; the instrument does not itself specify retroactive effect beyond what the statutory claim processes and decision-makers allow.

What the instrument requires, and what is left to other statutes, is expressed in the instrument’s operative text.

Duty to apply: Decision-makers handling claims under s 120B of the VEA or s 339 of the MRCA must apply this Statement as the RMA’s current Statement of Principles for TM (s 4, s 3). The instrument itself is a statement of medical opinion and prescriptive causal factors that must be considered when determining whether TM or death from TM is connected with relevant service.

Right to have causation assessed on RMA terms: Claimants have the procedural right, in the context of those statutory claims, to have causation assessed with reference to the factors set out in this Statement. If at least one of the factors in s 8 exists and is related to relevant service (s 9), then, according to the RMA, it can be said on the balance of probabilities that TM or death from TM is connected with service (s 8 opening, s 7). The mechanism is evidentiary: the presence of a listed factor provides the pathway to connection.

Evidentiary duty on claimants: To succeed, claimants must show (a) that TM as defined in s 6(2) applies to them, or that death was contributed to by TM (s 6(5)), (b) that at least one factor in s 8 is present, and (c) that the factor is related to the person’s relevant service (s 9(1)). Where the factor is an infection or drug exposure, timing is critical: the instrument requires those events to have occurred within two months before clinical onset (s 8(1), (2), (6), (7)). Where TM diagnosis requires imaging or CSF confirmation, claimants must provide those clinical records (s 6 note 2). For death claims, claimants must establish TS contributed to the terminal event listed in the Schedule (s 6(5); Schedule 1).

Duty to interpret exclusions: Decision-makers must interpret the exclusions listed in s 6(2)(b) when determining whether a person’s spinal cord disorder is TM within the meaning of this Statement or an excluded condition such as multiple sclerosis or neuromyelitis optica. The instrument makes clear the statutory meaning is the clinical definition given and not the ICD coding alone (s 6(3)-(4)).

Right to rely on other Statements: Where a factor in s 8 refers to an injury/disease that itself is the subject of another Statement of Principles, s 10 requires application of that other Statement’s factors according to its terms. Claimants and decision-makers have the right/duty to consult those Statements where the factor so requires.

No penalties or new obligations on clinicians: The Statement does not impose criminal or civil penalties or new reporting obligations on clinicians. Its effect is to define causation parameters for use in claims determinations; it does not itself direct clinical practice or compensation payments.

Limits on applicability: Section 9(2) limits the operation of factor 8(9) (inability to obtain appropriate clinical management) such that it applies only to material contribution or aggravation where the person’s TM was suffered or contracted before or during (but did not arise out of) relevant service. That narrows claims relying on lack of management to those cases involving pre-existing or concurrent TM, rather than TM that began as a result of service.

The instrument contains no criminal sanctions, civil penalties, administrative fines or private rights of enforcement in its text. It is a Statement of Principles made under s 196B(3) of the VEA (s 3) and designed to be applied within the statutory claims regime. The enforcement mechanism implicit in the instrument is administrative: the factors and definitions it sets will be applied by claim decision-makers when assessing whether TM or death from TM is connected with relevant service for the purposes of claims under s 120B VEA or s 339 MRCA (s 4, s 7-9).

What this implies practically:

• Application by decision-makers: The instrument is enforceable only through its use by statutory decision-makers in the VEA/MRCA claims process. It functions as authoritative medical guidance the RMA has determined should be used in adjudication. The instrument itself does not specify how decision-makers must record application or how procedural review should be conducted; those processes are governed by the VEA and MRCA provisions under which claims are made (s 4).

• No direct penalties: The Statement imposes no penalties on clinicians, claimants or administrators for non‑compliance with its findings. It does not create new offences, nor does it change evidentiary burdens beyond prescribing the factors and causal link that must be demonstrated to establish a connection to service.

• Evidentiary impact on claim outcomes: The practical “enforcement” role is indirect: if a claimant cannot establish the presence of at least one factor in s 8 and its relation to relevant service (s 9(1)), their claim to have TM or death from TM connected to service will, on the RMA’s view, fail the causation test. That affects entitlement outcomes under the VEA/MRCA.

• Cross-Statement enforcement: Where a listed factor refers to a disease covered by another Statement, s 10 directs decision-makers to apply the factors in that other Statement. This creates an implicit enforcement network among RMA Statements that can affect claim outcomes across multiple instruments.

• Administrative discretion: The Statement leaves certain evaluative determinations to decision-makers, for example whether a factor is related to relevant service (s 9(1)), or whether inability to obtain appropriate clinical management materially contributed or aggravated TM (s 9(2)). Those are matters of adjudicative assessment rather than penalties.

In short, the instrument alters the evidentiary landscape and therefore the adjudicative outcomes in claims, but it does not itself create enforcement sanctions. Its practical effect is through administrative application within the statutory claim processes referenced in s 4.

Direct statutory linkage: The Statement is expressly made under subsection 196B(3) of the VEA (s 3) and applies to claims to which section 120B of the VEA or section 339 of the MRCA apply (s 4). Therefore, its operation is subordinate to, and integrated with, the statutory provisions and procedural rules in those Acts governing claims, evidence, and entitlements. The instrument does not supplant the VEA or MRCA; it provides the RMA’s medical causation framework to be used within the decision-making processes established by those statutes.

Cross‑reference to other Statements of Principles: Section 10 creates a direct interaction rule. If a factor in s 8 refers to an injury or disease that is covered by another RMA Statement made under s 196B(3) of the VEA, then the factors in that other Statement “apply in accordance with the terms of that Statement as in force from time to time” (s 10(1)-(2)). Practically, this requires claimants and decision-makers to cross-check and apply multiple Statements where etiological factors overlap. For example, if a factor refers to a malignant neoplasm that has its own Statement of Principles, the decision-maker must apply the other Statement’s factors and definitions when assessing the presence and causal relevance of that neoplasm.

Interaction with diagnostic coding and hospital classification: The Statement notes that, while TM is associated with ICD‑10‑AM code G37.3, the statutory meaning is as defined in s 6(2) (s 6(3)-(4)). That means that diagnostic coding or hospital classification alone is not decisive; decision-makers must apply the clinical definition in the Statement when assessing claims.

Relationship to clinical standards and evidence law: The Statement relies on “sound medical‑scientific evidence” as the basis for its conclusions (s 7). While it does not itself define evidentiary rules, it interacts with statutory rules on admissible evidence and standards of proof in the VEA/MRCA claims processes: claimants must marshal clinical evidence (imaging, CSF, microbiology, pathology, vaccine and drug records, transplant history) that conforms to the Statement’s diagnostic and temporal requirements.

No conflict with other law stated: The instrument does not assert that it overrides other statutes or legal instruments. Its function is to be applied within the statutory framework of the VEA and MRCA. Where overlap occurs with other legal provisions (for example, general public law duties, privacy or health records regimes), the instrument is silent; decision-makers must reconcile requirements in accordance with the governing statutes and administrative law.

Temporal interaction: The instrument commences on 21 June 2021 (s 2) but does not state a cut‑off for claims that arose prior to that date. Its application will therefore be governed by the VEA/MRCA procedural rules and any transitional arrangements those statutes or administrative practice impose. The instrument itself does not specify retrospective or prospective application beyond its commencement date.

The instrument document supplied carries these dates and identifiers only: it is the Statement of Principles concerning transverse myelitis (Balance of Probabilities), numbered No. 72 of 2021; it is dated 21 May 2021 and its commencement is 21 June 2021 (s 1-2 and topmatter). The instrument was sealed by the Repatriation Medical Authority and signed under the Common Seal by the Chairperson (document seal page). No amendments, revocations, prior versions or subsequent variations are recorded within the text provided.

There is no schedule of amendments in the instrument itself and no footnoted history of prior Statements in the text supplied. The instrument’s s 10 anticipates that other Statements of Principles will be “in force from time to time” and thus may be amended, but this instrument as provided contains no amendment history.

Practical implication for users: Decision-makers and claimants must check whether subsequent RMA instruments, or legislative changes to the VEA or MRCA, have occurred since this instrument’s commencement date when preparing or deciding claims. The instrument itself does not list or record amendments, so an external check on the RMA register or consolidated statutory instruments will be necessary to confirm currency. The Schedule’s cross-statement provision (s 10) reinforces the need to consult the current text of any other relevant RMA Statements.

The text of this Statement contains no record of litigation, court challenges, judicial reviews or case law discussing or construing this instrument. It does not cite any judicial decisions and provides no history of disputes. The instrument is an administrative instrument issued by the Repatriation Medical Authority under s 196B(3) of the VEA (s 3), and any litigation history (if any exists) would be external to the document provided.

Practical note for litigators and reviewers: Because no litigation history is reported within the instrument, practitioners should not assume there has been judicial consideration of the RMA’s factors for TM. Where an adverse administrative decision arises that relies on this Statement, affected parties may have avenues of review or appeal under the VEA or MRCA regimes or administrative law principles. Any such litigation would involve assessing whether decision-makers applied the Statement correctly, whether evidence met the balance of probabilities requirements, and whether other statutory procedural requirements were observed. The instrument itself does not enumerate review rights or procedures; those will be found in the VEA/MRCA and associated administrative law.

The instrument contains specific technical features and narrow formulations that can be decisive in claims. Below are concrete points where claimants, clinicians, and decision-makers commonly misread the instrument or encounter practical traps, with references to the relevant sections.

1. Clinical definition versus coding (s 6(2)-(4)). The Statement stresses that, although TM attracts ICD‑10‑AM code G37.3, the statutory meaning is the clinical definition in s 6(2). Relying on hospital discharge coding alone will not meet the Statement’s requirement; confirmatory clinical evidence (neuroimaging or CSF) is noted as usual (s 6 note 2).

2. Explicit exclusions (s 6(2)(b)). Several conditions commonly in the differential diagnosis of spinal cord disorders are expressly excluded: multiple sclerosis and neuromyelitis optica among others. A diagnosis labelled “myelitis” must be evaluated against these exclusions. If the underlying pathology is one of the excluded conditions, the claim may fall outside this Statement’s scope.

3. Timing precision for infection and drug exposure (s 8(1), (2), (6), (7)). Several qualifying factors require the event within two months before clinical onset. Clinical records must show the timing: a generic statement of “recent infection” without dates may be insufficient. Similarly, drug exposure must be within two months before onset for s 8(6). For oral polio vaccine, s 8(7) imposes the same two‑month window.

4. Unbounded or ambiguous timeframes (s 8(8), (9)). Having had a bone marrow or stem cell transplant is qualified as “before the clinical onset” but without a specified maximum interval (s 8(8)). That opens interpretive questions about how remote prior transplants factor; decision-makers will need to assess causal plausibility. “Inability to obtain appropriate clinical management” (s 8(9)) is potentially vague. Section 9(2) narrows its application: it applies only to material contribution or aggravation where TM was suffered or contracted before or during (but did not arise out of) the person’s relevant service. So the “inability to obtain appropriate clinical management” factor is not available for TM that arose out of service.

5. Requirement that the factor be related to relevant service (s 9(1)). The presence of a factor alone is not enough. For example, an infection suffered post‑service, where service does not relate to the infection, will not satisfy s 9(1). Claimants must show a relationship between the factor and their relevant service. The instrument does not define “related to” in detail, leaving room for adjudicative assessment.

6. Death claims and “contributed to” standard (s 6(5)). Death from TM is included where TM contributed to the terminal event. The Schedule’s terminal event definition lists several proximate physiological causes (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function). Practitioners should map the cause-of-death chain carefully: the Statement requires TM to have contributed to the terminal event rather than being an incidental finding.

7. Cross-Statement complexity (s 10). If a factor refers to an injury/disease governed by another Statement, the rules of that other Statement apply. That requires claimants and decision-makers to read multiple RMA instruments and to reconcile possibly differing temporal windows, definitions or exclusions.

8. “Specified list of drugs” breadth (Schedule 1). The Schedule defines this as biologic agents for the treatment of cancer or tumour necrosis factor‑α inhibitors. The definition of “biologic agent” is given in the Schedule with examples in the note (tyrosine kinase inhibitors, immune checkpoint inhibitors, dinutuximab). Practitioners must determine if a prescribed or administered drug falls within this definition; brand names or off‑label uses may require pharmacological identification and expert evidence.

9. Diagnostic confirmation expectations (s 6 note 2). The Statement notes TM diagnosis “can be confirmed” by evidence of spinal cord inflammation on neuroimaging or CSF analysis. Where such confirmatory tests are absent or equivocal, decision-makers must evaluate whether the balance of probabilities is met. Lack of definitive imaging/CSF substantially raises the evidentiary bar.

10. No procedural detail on application (s 4). The instrument does not set out procedural expectations for evidence submission, timeframes, or standards for service-relatedness; those procedural rules are in the VEA and MRCA. Practitioners must therefore coordinate compliance with both the Statement’s substantive test and the procedural requirements of the underlying statutes.

11. Non-amendment record (Amendment history section). The provided instrument contains no record of subsequent amendments or revocations; practitioners must confirm whether a later RMA Statement has superseded or varied this instrument.

These “gotchas” are about interpretive traps, evidentiary gaps, and the need to reconcile temporal and definitional precision across medical records, service records and other RMA Statements.

For claimants, clinicians, and decision‑makers preparing or assessing claims that invoke this Statement, compliance means assembling and presenting the specific evidence that aligns with the Statement’s definitions, temporal windows and linkage requirement.

1. Establish the diagnosis of transverse myelitis as defined (s 6(2)). Obtain and supply contemporary clinical records that show the acute or subacute onset of spinal cord dysfunction (motor, sensory, autonomic). Because the Statement notes diagnosis can be confirmed by neuroimaging or CSF analysis (s 6 note 2), include spinal MRI reports, radiology images, and CSF laboratory reports where available. Explicitly address and exclude the conditions listed in s 6(2)(b) in clinical opinion: for example, demonstrate how multiple sclerosis, neuromyelitis optica, spinal cord compression, trauma and tumour invasion have been ruled out.

2. Demonstrate presence of at least one listed factor (s 8). The evidence needed will depend on which factor is relied on:

• For symptomatic gastrointestinal or respiratory infection within two months before clinical onset (s 8(1)): produce clinical consultation notes, microbiology results, hospital records, or laboratory confirmation with dates that establish symptom onset and dates relative to the TM clinical onset.

• For infection with a viral, bacterial, fungal or parasitic organism within two months before clinical onset (s 8(2)): provide microbiology culture results, PCR tests, serology, or specialist infectious diseases notes identifying the organism with dates.

• For systemic autoimmune disease at the time of clinical onset (s 8(3)): supply rheumatology or immunology diagnosis notes, serological test results, and contemporaneous treatment records showing the autoimmune disease was present at the time of TM onset.

• For sarcoidosis at the time of clinical onset (s 8(4)): provide histopathology, imaging, specialist notes and treatment records showing sarcoidosis was present at onset.

• For malignant neoplasm (other than non-melanotic malignant neoplasm of the skin) at the time of clinical onset (s 8(5)): provide oncology records, pathology reports, imaging, and treatment records; note the Statement recognises paraneoplastic presentations and that the malignancy may be present but undiagnosed at onset (s 8 note).

• For taking a specified drug within two months before clinical onset (s 8(6)): document prescriptions, administration records, pharmacy dispensing records and dates. Where brand names or combination therapies exist, confirm drug class and whether it falls within “biologic agents for the treatment of cancer” or “tumour necrosis factor‑α inhibitors” (Schedule 1).

• For receiving oral polio vaccine within two months before clinical onset (s 8(7)): supply vaccination records, immunisation registers, and dates.

• For bone marrow or stem cell transplant before clinical onset (s 8(8)): supply transplant operative records, transplant unit notes, follow‑up clinic letters, and date of transplant.

• For inability to obtain appropriate clinical management (s 8(9)), and where applicable under s 9(2): gather records demonstrating attempts to access care, referral letters, evidence of service limitations, dates showing TM was suffered or contracted before or during (but did not arise out of) relevant service, and clinical evidence that inadequate management materially contributed to or aggravated TM.

3. Establish relationship to relevant service (s 9(1); Schedule 1). Compile service records to show relevant service category (eligible war service, defence service, or MRCA peacetime service) and evidence linking the factor to service (for example, infection acquired during deployment, drugs administered as part of service medical care, vaccine given in service, or inability to access appropriate clinical management related to service circumstances). The Statement requires the factor be related to the person’s relevant service; documentary evidence from service health records, deployment reports, and contemporaneous unit medical logs will be important.

4. For death claims, document causation chain (s 6(5); Schedule 1). Obtain the death certificate, cause-of-death documentation, terminal event records (diagnoses of pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function), and evidence that TM contributed to the terminal event.

5. Cross-check other RMA Statements where applicable (s 10). If a factor points to an injury or disease that has its own Statement (for example, an identified malignancy or autoimmune disease with its own Statement), obtain and align evidence to the factors in that Statement, because s 10 requires application of the other Statement’s factors.

6. Provide expert medical opinion addressing the balance of probabilities (s 7). Secure specialist medical reports that explain, on the balance of probabilities, how the clinical evidence meets the RMA’s factors and how the factor is related to relevant service. Where complex pharmacology, infectious disease or oncology issues arise, obtain specialist reports that address the specific element of causation under the Statement.

7. Be precise about timing. Where the Statement requires events within two months before clinical onset (s 8(1), (2), (6), (7)), provide clear dates and timelines juxtaposing infection onset, drug administration, vaccine dates and TM clinical onset. Ambiguity on timing is a common reason for adverse findings.

8. Address exclusions head-on (s 6(2)(b)). If there is any diagnostic uncertainty with respect to excluded conditions (e.g., neuromyelitis optica), obtain targeted diagnostic testing and expert commentary to exclude those causes under the Statement.

9. Maintain a chain of documentary evidence. Medical records, test results, service records, prescription and vaccination documentation, and correspondence demonstrating attempts to obtain care will be central. Where primary records are incomplete, contemporaneous affidavits or statements from treating clinicians or commanding officers may assist, but will need to be aligned with the medical evidence and statutory tests.

10. Check currency and interacting Statements. Before lodging evidence or relying on this Statement, confirm it remains in force and whether any subsequent RMA Statements affect interpretation or introduce different factors. This instrument contains no amendment history in the supplied text; practitioners must verify whether subsequent RMA Instruments have been issued.

Following these steps aligns practical evidence with the Statement’s structure: diagnosis as defined in s 6; at least one factor from s 8 present; the factor related to relevant service under s 9; and, where relevant, application of other RMA Statements under s 10.