Statement of Principles concerning umbilical hernia, peri-umbilical hernia and para-umbilical hernia (Reasonable Hypothesis) (No. 91 of 2025)

The instrument revolves around a narrow set of legal-medical concepts that determine when a “reasonable hypothesis” exists linking umbilical-region hernias or death from those hernias to relevant service. These core concepts are:

• Condition definition: The SoP adopts a clinical definition of umbilical, peri-umbilical and para-umbilical hernia as a protrusion of intra-abdominal tissue through a defect in the abdominal wall in the umbilical region, and expressly excludes incisional hernia located at the umbilicus (s 7(2)). The instrument notes associated clinical worsening (enlargement, obstruction, incarceration, strangulation or rupture) but does not attempt a broader nosology beyond the definition and the relevant ICD-10-AM codes referenced (s 7(3)-(4)).

• Reasonable hypothesis threshold: The RMA sets out specific factors, at least one of which must exist before a reasonable hypothesis can be said to be raised connecting the condition (or death from it) with relevant service (s 9). The SoP functions as the RMA’s medical-scientific template for the “reasonable hypothesis” threshold used in claims assessment under the VEA and MRCA.

• Factors and temporal nexus: The listed factors operate either at the time of clinical onset or at the time of clinical worsening (s 9). The factors include: BMI of 30 or greater at the time of onset or worsening (s 9(1)); chronic elevation of intra‑abdominal pressure at time of onset (s 9(2)); sustained heavy lifting exposure (lifting heavy loads for at least one hour per day, on more days than not, over at least 12 months before onset) (s 9(3)); acute or chronic elevation of intra‑abdominal pressure at time of worsening (s 9(4)); and inability to obtain appropriate clinical management prior to clinical worsening (s 9(5)).

• Relationship to relevant service: Any factor relied on must be related to the person’s relevant service as defined in Schedule 1 (s 10(1)). The instrument sets a particular rule for the clinical worsening factors: they apply only where the hernia was suffered or contracted before or during (but did not arise out of) relevant service, and where the worsening is a material contribution to, or aggravation of, the condition (s 10(2)). This creates a temporal and causal limitation on how clinical worsening operates as a basis for claims.

• Interdependence with other SoPs: Where a factor in s 9 refers to an injury or disease covered by another SoP determined under s 196B(2) of the VEA, the other SoP’s factors apply according to its terms (s 11). This mechanism ties cross-condition causal pathways to the RMA’s determinations in other instruments.

• Medical coding and definition primacy: While the instrument records ICD-10-AM codes applicable to these hernias (K42.0, K42.1, K42.9), it emphasises that the statutory meaning is the definition in s 7(2) (s 7(3)-(5)). The ICD-10-AM reference indicates correspondence with clinical classification but does not displace the instrument’s own definitional text.

• Death inclusion: The SoP includes death caused or contributed to by the hernia as within scope for claims assessment (s 7(6)). “Terminal event” is expressly defined in the Schedule to include pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function, among others (Schedule 1).

These concepts together delimit the factual hooks adjudicators will test when assessing whether relevant service can reasonably be connected to an umbilical-region hernia or death from it. The instrument mixes fixed definitional text (the phenotype of the condition, exclusion of incisional hernia), quantified exposure thresholds (BMI ≥ 30; lifting criterion) and qualitative/conceptual thresholds (chronic elevation of intra-abdominal pressure; inability to obtain appropriate clinical management).

Directly, the SoP affects persons making claims under the VEA or the MRCA where s 120A of the VEA or s 338 of the MRCA apply (s 5). The instrument’s definitions of “relevant service” in Schedule 1 show which categories of service are captured: operational service, peacekeeping service and hazardous service under the VEA; British nuclear test defence service under the VEA; and warlike and non-warlike service under the MRCA (Schedule 1). Thus, recipients or former members of the Australian Defence Force and certain other classes defined in the VEA/MRCA will be within the scope if they assert a link between their hernia and relevant service.

Stakeholders affected include:

• Claimants (veterans, ex‑members, dependants pursuing death claims): Their ability to have a reasonable hypothesis raised turns on satisfying one or more of the factors in s 9 and on showing the factor(s) are related to their relevant service (s 10(1)). Death claims are specifically in scope where death was contributed to by the hernia or by a terminal event to which the hernia contributed (s 7(6)).

• Medical assessors and decision-makers: The RMA has supplied these criteria for use in adjudication of claims under the VEA and MRCA. Medical officers, claims assessors and reviewers must apply the SoP factors to determine whether a reasonable hypothesis exists. The SoP clarifies the medical-scientific evidence the RMA regards as sound for this condition (s 8).

• Administrators and record-holders: Where factors require factual proof , for example BMI at time of clinical onset or evidence of lifting exposure over specified durations and intensities (s 9(1), s 9(3)) , administrators and claimants will need medical records, employment or service records, or other documentation to support claims.

• Providers of care: The SoP recognises “inability to obtain appropriate clinical management” as a factor (s 9(5)). Health services, Defence medical services and external providers will be implicated indirectly as their availability, timeliness and contemporaneous records may influence whether the inability-to-treat factor is established.

Indirectly, the SoP affects the Departmental decision processes and potentially tribunal review, insofar as this instrument establishes the medical baseline used to decide reasonable-hypothesis questions. The instrument does not alter statutory entitlement criteria in the VEA or MRCA themselves; it feeds into the factual determination necessary to trigger those statutes’ processes (s 5).

The instrument also affects cross-SoP applications: where a s 9 factor refers to another injury or disease covered by an existing SoP, that other SoP governs the application of that factor (s 11), which spreads impact across multiple SoPs and the persons whose claims involve multi-factor pathologies.

Who does not fall within scope: persons whose condition is an incisional hernia at the umbilicus are explicitly excluded (s 7(2)(b)). Also, the SoP applies only to claims to which the identified sections of the VEA or MRCA apply (s 5); private litigants or non‑service-related claims outside those statutory schemes are not directly affected by this instrument.

This instrument does not itself create statutory duties in the sense of criminal offences or civil obligations, nor does it itself confer monetary entitlements. Instead, its operative effect is to define the medical factors that must be present to raise a reasonable hypothesis linking the condition or death to relevant service for the purposes of claims assessment under the VEA and MRCA. The key procedural and evidentiary rights and duties flow from that role.

Rights and procedural effects for claimants:

• Right to have a claim assessed against these medical criteria: A claimant whose situation falls within the statutory scope (s 5) is entitled to have the question whether there is a reasonable hypothesis assessed using this SoP. The RMA states it has “sound medical‑scientific evidence” that the condition can be related to relevant service (s 8), which is the evidentiary base for using these factors in claims evaluation.

• Right to rely on listed factors: If at least one factor in s 9 exists and is shown to be related to the claimant’s relevant service (s 10(1)), a reasonable hypothesis may be raised. Claimants therefore have the procedural right to adducing evidence that meets one or more of those factors.

Duties and evidentiary implications:

• Duty to establish relation to relevant service: The instrument requires that any factor relied on must be related to the person’s relevant service (s 10(1)). That places an evidentiary duty on claimants to adduce material linking the factor (for example, a period of heavy lifting or a chronic condition causing elevated intra‑abdominal pressure) to service activity or circumstances.

• Duty to show temporal-causal constraints for clinical worsening: For claims relying on clinical worsening, s 10(2) confines those factors to cases where the hernia was suffered or contracted before or during (but did not arise out of) relevant service, and where the worsening materially contributed to or aggravated the condition. That places a two-part burden: (a) to establish the pre-existence of the hernia prior to a worsening event, and (b) to show that the worsening is materially linked to the service-related factor.

• Duty to engage cross‑SoP rules where applicable: Where a s 9 factor refers to another disease or injury covered by a separate SoP, the claimant must meet the terms of that other SoP as it stands (s 11). This imposes an additional duty to identify and satisfy other SoPs where the causal chain includes another covered condition.

Administrative obligations (implicit):

• Decision-makers must apply the SoP: The RMA determined the SoP under its statutory role (s 3 and s 8). Administrative bodies that adjudicate claims under the VEA and MRCA will be required to apply the medical criteria contained in the SoP when assessing whether a reasonable hypothesis exists. The instrument itself does not set out how decision-makers must document findings; that procedural detail is controlled by the VEA/MRCA and administrative practice.

No penalties or enforcement mechanisms are contained within this instrument. It does not create offences, civil penalties, or administrative sanctions for non‑compliance by third parties. The “duties” described above are evidentiary and procedural pressures that arise from the SoP’s role in claims assessment, not from stand‑alone coercive provisions in the instrument itself.

The Statement of Principles itself contains no penal provisions, fines, criminal offences, or express enforcement mechanisms. The instrument is a medical‑scientific determination under subsection 196B(2) of the VEA (s 3) and functions as an evidentiary and adjudicative tool used in claims assessment under the VEA and MRCA (s 5). It does not purport to create or modify statutory penalties or administrative sanctions.

Consequently:

• There are no penalties in the SoP for failing to satisfy the listed factors. The SoP sets criteria for whether a “reasonable hypothesis” is raised; failure to meet those criteria affects the outcome of a claims assessment under the VEA or MRCA, not an independent penalty in the SoP itself.

• Enforcement of entitlements, or denial thereof, occurs through the primary statutes and administrative decisions those statutes prescribe. The SoP must be applied in the evaluation of claims to which s 120A of the VEA or s 338 of the MRCA applies (s 5), and any remedies, review rights or litigation would depend on the VEA, MRCA and their associated administrative and tribunal review processes. The instrument does not specify appeals, review periods, or decision‑maker identity for enforcement.

• Medical or factual disputes arising from application of the SoP (for example, contested BMI measurements at time of clinical onset, or whether lifting exposure satisfied the stated threshold) will be resolved in the claims process that operates under the VEA or MRCA. The SoP provides the medical parameters but not adjudicative processes.

Where the SoP cross‑refers to other SoPs (s 11), disagreements over the application of those other SoPs will similarly follow the review and enforcement pathways associated with the VEA/MRCA and the administrative arrangements for Veterans’ claims. The instrument therefore operates as authoritative medical guidance within the statutory claims machinery, but it does not itself prescribe enforcement or penalty regimes.

The instrument is expressly made under the VEA (s 3) and applies to claims to which specific provisions of the VEA and the MRCA apply (s 5). Interaction with other legal instruments happens through several explicit channels:

• Primary statute dependence: This SoP is a determination under s 196B(2) of the VEA (s 3). Its legal role is to inform the “reasonable hypothesis” step in claims under the VEA and MRCA. The SoP does not itself grant entitlements or create administrative rights; it must be read alongside the substantive provisions of the VEA and MRCA that confer, deny, or determine compensation and rehabilitation (s 5).

• Cross-SoP application: Section 11 creates a mechanism to incorporate other SoPs where s 9 factors refer to injuries or diseases covered by other SoPs. If a s 9 factor refers to an injury/disease covered by another RMA SoP determined under s 196B(2) of the VEA, then the factors in that other SoP “apply in accordance with the terms of that Statement of Principles as in force from time to time” (s 11). This ties the present instrument into the RMA’s broader body of SoPs and means that interactions with other laws will include the ways those other SoPs themselves interact with legislation and administrative practice.

• Clinical classification reference: The SoP references ICD‑10‑AM codes (K42.0, K42.1, K42.9) and specifies the particular edition and effective date it relies on (Tenth Edition, effective date 1 July 2017) (s 7(4)-(5)). This connects the SoP to a recognised clinical classification system, which may be used in other statutory or regulatory contexts that refer to ICD coding. The instrument nonetheless states that, in applying the SoP, the meaning of the condition is that given in subsection 7(2), i.e. the instrument’s textual definition takes precedence for legal application (s 7(3)).

• Relationship with VEA/MRCA definitions: The Schedule 1 dictionary imports or defines key terms such as “relevant service”, “MRCA” and “VEA” and “terminal event” (Schedule 1). Those definitions determine which forms of service are included when the VEA or MRCA provisions referenced in s 5 are applied. The SoP therefore interacts with the VEA and MRCA definitions to define the population to which it applies.

• Repeal of prior SoP: The instrument repeals the earlier No. 93 of 2016 SoP (s 4). That repeal is an internal interaction within the body of RMA instruments and means that decision-makers must apply this SoP instead of the 2016 version for claims within its commencement window (s 2, s 4).

• Administrative practice and review regimes: Although not set out in this text, the SoP’s effective operation depends on and interacts with the administrative decision-making, record-keeping and review regimes established under the VEA and MRCA and associated regulations. For example, the process for calculating BMI at a relevant time, documenting “inability to obtain appropriate clinical management,” or verifying lifting exposures will be processed through the mechanisms established under the primary statutes and departmental practice.

The SoP therefore functions as a technical medical instrument embedded within a statutory claims framework. It does not displace the VEA or MRCA but must be applied in concert with those Acts, other SoPs and the clinical classification system referenced.

The instrument contains a brief self-contained amendment history limited to the repeal of a prior RMA instrument. The text records:

• This Statement of Principles concerning umbilical hernia, peri-umbilical hernia and para-umbilical hernia (No. 91 of 2025) was made by the Repatriation Medical Authority and dated 24 October 2025 (front matter).

• Commencement is 24 November 2025 (s 2). The instrument thus takes effect one month after the date on the instrument.

• Repeal: The instrument expressly repeals the Statement of Principles concerning umbilical hernia (Reasonable Hypothesis) (No. 93 of 2016) (Federal Register of Legislation No. F2016L01673), which was made under subsection 196B(2) of the VEA (s 4). No other prior amendments, replacements, or transitional provisions appear in the text.

No other amendments, schedules, saving clauses, transitional arrangements or modifications to existing SoPs are included. There is no retrospective application clause stated. The only history recorded in this instrument is the supersession of the 2016 SoP by the present (No. 91 of 2025) instrument effective from the stated commencement date.

Because the instrument incorporates the words “as in force from time to time” when referring to other SoPs (s 11), future amendments to other SoPs will affect application where cross-references arise; however, the instrument does not itself set a mechanism for amendment beyond the RMA’s statutory power under s 196B(2) of the VEA. Any further amendment history would be recorded in subsequent instruments or in the Federal Register of Legislation.

The text of this Statement of Principles does not contain any judicial or tribunal decisions, nor does it cite or record any litigation in which the RMA’s determinations have been contested. The instrument’s repeal of the 2016 SoP is recorded (s 4), but there is no mention of appeals, test cases, or precedent in the document itself.

Therefore, based solely on the provided instrument:

• There is no litigation history or case law cited in the instrument that interprets or applies this particular SoP.
• No judicial or tribunal findings about the meaning, scope or application of the factors listed in s 9 are included in the text.

Users requiring litigation context must look to decisions under the VEA and MRCA that reference RMA SoPs in claims or judicial review proceedings; such materials are not present in the instrument provided. The instrument does show, however, the RMA’s view that there is “sound medical‑scientific evidence” supporting a relationship between the condition and relevant service (s 8), which is the RMA’s evidentiary posture but not a substitute for judicial application or commentary.

The instrument contains several features and textual choices that create practical pitfalls for claimants, decision-makers and advisers. Below are concrete issues to watch for, grounded in the specific provisions:

• Strict definitional scope and explicit exclusion: The definition in s 7(2) focuses on protrusion of intra‑abdominal tissue through a defect in the abdominal wall in the umbilical region and explicitly excludes incisional hernia located at the umbilicus (s 7(2)(b)). A claimant whose condition is categorised or coded as an incisional hernia at the umbilicus will be out of scope regardless of other factors.

• Primacy of textual definition over ICD code: Although the SoP notes the applicable ICD‑10‑AM codes (K42.0, K42.1, K42.9) (s 7(4)), it states that the meaning for applying the SoP is the textual definition in s 7(2) (s 7(3)). A record that simply lists an ICD code without clinical detail may not establish the required phenotype under the statutory definition.

• BMI timing and measurement: The BMI factor requires a Body Mass Index of 30 or greater “at the time of clinical onset or clinical worsening” (s 9(1)). The instrument supplies the BMI formula (W/H2) in the note under s 9 (note to s 9(1)). Evidence of BMI at the exact relevant time may be sparse; contemporaneous medical records showing weight and height at onset or worsening are necessary. Using later or earlier measurements risks not meeting the precise temporal requirement.

• Heavy lifting threshold is specific and demanding: The lifting factor requires “elevation of pressure within the abdominal cavity due to lifting heavy loads for at least 1 hour per day, on more days than not, over a period of at least 12 months before clinical onset” (s 9(3)). This is a quantifiable and relatively high exposure threshold; proving this specific frequency and duration using service records, role descriptions, or witness statements may be difficult. Casual descriptions of strenuous work that do not meet the “1 hour per day, more days than not, for at least 12 months” standard could fail.

• “Chronic elevation of pressure” and examples: The instrument provides examples of conditions that can cause chronic elevation of intra‑abdominal pressure (ascites, peritoneal dialysis, extensive intra‑abdominal neoplastic disease, pregnancy) (note to s 9(2)). These are examples, not an exhaustive list, but claimants must show the presence of chronic elevation at the time of clinical onset. The qualifier “chronic (intermittent or continuous)” adds conceptual complexity: episodic conditions causing intermittent increases in intra‑abdominal pressure may or may not meet the requirement depending on the facts.

• Clinical worsening limitations and pre‑existence rule: Section 10(2) restricts the clinical worsening aspect to circumstances where the hernia was suffered or contracted before or during (but did not arise out of) relevant service. This creates a potential evidentiary trap: if the hernia arose out of relevant service (i.e. it is said to have arisen because of service), then clinical worsening after service cannot be used as a material contribution/aggravation factor under s 10(2). The claimant must show a pre-existing hernia and that service‑related factors materially worsened it.

• “Inability to obtain appropriate clinical management” is vaguely framed: The SoP lists as a factor the inability to obtain appropriate clinical management before clinical worsening (s 9(5)), but provides no statutory standard for what constitutes “appropriate” management or what evidentiary threshold will be applied to prove inability to obtain it. Decision-makers will have to assess this on the facts; contemporaneous clinical notes, referrals, wait lists, and correspondence will be critical evidence, but the instrument itself does not define the evidentiary standard.

• Cross-SoP dependencies: When a s 9 factor refers to another injury/disease covered by a different SoP, the other SoP controls (s 11). This creates the need to identify and satisfy multiple technical instruments; failing to identify a relevant SoP could lead to incorrect application of the RMA’s criteria.

• Death causation includes “terminal event” contribution: For death claims, the SoP includes death from a terminal event or condition that was “contributed to by” the hernia (s 7(6)). Schedule 1 defines “terminal event” with non-exhaustive examples (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function). The "contributed to" standard is potentially lower than sole causation, but the instrument provides no technical test for contribution beyond inclusion; claimants must demonstrate some causal contribution of the hernia to the terminal event.

• Repeal without transitional text: The instrument repeals the 2016 SoP (s 4) but includes no transitional provisions explaining treatment of claims in progress at the commencement date. Practitioners must check administrative practice or the primary statutes to see whether new claims post-commencement are governed by the new SoP and how pending claims are affected.

• Reliance on an older ICD edition: The instrument relies on the ICD‑10‑AM Tenth Edition effective 1 July 2017 (s 7(4)). While this establishes a fixed reference point, use of an older edition may raise coding interpretation issues where medical records use later editions; the SoP’s textual definition is controlling (s 7(3)), but coding discrepancies can complicate records review.

These are concrete operational pitfalls that turn on the instrument’s text. They create evidentiary burdens and definitional thresholds that must be navigated by claimants, advisers and decision-makers.

Compliance in this context means assembling and presenting the factual and medical evidence necessary for decision-makers to apply the SoP and determine whether a reasonable hypothesis is raised linking the hernia (or death) to relevant service. The SoP identifies specific factors and definitional elements; practical steps for claimants and their advisers, grounded in those provisions, are as follows.

1. Establish the condition under the SoP definition (s 7(2) and s 7(3)):

   • Ensure medical records describe the condition in terms consistent with the instrument: a protrusion of intra‑abdominal tissue through a defect in the abdominal wall at the umbilicus. Explicitly exclude incisional hernia at the umbilicus, or obtain clinical confirmation the condition is not an incisional hernia (s 7(2)(b)).
   • Where records use ICD coding, note the codes K42.0, K42.1, K42.9 correspond to these hernias (s 7(4)), but also ensure the textual clinical description aligns with s 7(2) because the SoP’s meaning is the text (s 7(3)).

2. Match evidence to the listed factors (s 9):

   • BMI factor (s 9(1)): Produce contemporaneous clinical notes, weight and height recordings or military medical records demonstrating BMI of 30 or greater at the time of clinical onset or clinical worsening. Use the provided BMI formula (W/H2) if computation is necessary and document the dates corresponding to the onset or worsening.
   • Chronic elevation of intra‑abdominal pressure (s 9(2)): Provide medical evidence of conditions such as ascites, peritoneal dialysis, intra‑abdominal neoplastic disease, or pregnancy at the time of clinical onset, or other documented causes of chronic intra‑abdominal pressure. The instrument’s note lists examples,support with test results, specialist notes, procedure records or chronic disease management records.
   • Heavy lifting exposure (s 9(3)): For the 1 hour/day, more days than not, over at least 12 months threshold, compile duty statements, unit logs, service role descriptions, workplace injury records, sworn witness statements, or other contemporaneous documentation showing the frequency and duration of heavy lifting during the relevant pre-onset period.
   • Acute/chronic elevation at time of clinical worsening (s 9(4)): Provide medical notes documenting episodes of significant coughing, vomiting, heavy lifting, pregnancy, or other acute/chronic pressure-raising events temporally linked to the clinical worsening episode.
   • Inability to obtain appropriate clinical management (s 9(5)): Assemble referral letters, wait‑list notices, correspondence with health services, denial letters, or records showing absence of access to surgical or specialist care prior to clinical worsening. Contemporaneous clinical notes indicating recommended management and failure to obtain it will be particularly probative.

3. Demonstrate relation to relevant service (s 10(1)):

   • For any factor relied on, provide material connecting that factor to the person’s relevant service as defined in Schedule 1 (operational, peacekeeping, hazardous or British nuclear test defence service under the VEA; warlike or non‑warlike service under the MRCA). Military duty rosters, postings, tasking documents, service medical records, and commanding officer statements can demonstrate this nexus.

4. Address clinical worsening rules (s 10(2)):

   • If relying on clinical worsening as the basis for service connection, confirm the timeline: the hernia must have been suffered or contracted before or during (but did not arise out of) relevant service. Evidence should show pre‑existence of the hernia and the timing of the worsening. Provide documentation proving that the worsening was a material contribution to or aggravation of the condition, such as progression notes, surgical findings, or specialist reports.

5. Consider cross-SoP implications (s 11):

   • If a s 9 factor refers to another injury or disease covered by a different SoP, identify the other SoP and ensure the person meets its factors. For example, if a chosen factor relates to a disease that itself requires particular evidence under another SoP, gather the evidence required by that SoP in addition to the evidence addressing s 9.

6. Prepare records for death claims (s 7(6) and Schedule 1):

   • For death claims, assemble the death certificate, autopsy or coroner’s reports, terminal event documentation and medical opinions connecting the hernia to the terminal event. Because the SoP includes death “from a terminal event or condition that was contributed to by” the hernia, medical expert opinion demonstrating contribution (not necessarily sole causation) will be important.

7. Anticipate evidentiary weaknesses and pre-empt them:

   • Where contemporaneous records are thin, obtain retrospective expert medical opinions that carefully anchor findings to available records and to the SoP’s temporal requirements. However, note the SoP’s emphasis on timing (onset vs worsening) and that retrospective inference will be scrutinised against those timepoints.

8. Document coding and definitional alignment:

   • Where records use different ICD editions or shorthand clinical labels, procure clinician statements clarifying that the recorded diagnosis corresponds to the SoP definition (s 7(3)-(5)). Given that the SoP fixes an ICD edition for reference (s 7(4)), inclusion of clinician confirmation reduces ambiguity.

9. Track commencement and repeal dates for claims sequencing (s 2, s 4):

   • Be mindful of the SoP’s commencement date (24 November 2025) and the repeal of the 2016 SoP (s 2, s 4). For claims straddling commencement, consult departmental guidance to confirm which SoP applies and whether transitional administrative practices exist. The instrument itself contains no transitional clause.

10. Use the instrument as a checklist in medico-legal reports:

    • Advisers and clinicians preparing medical reports for claims should address each potentially relevant s 9 factor explicitly, state whether it is present or absent, and link each present factor to the person’s relevant service (s 10(1)). If relying on cross‑SoP factors, note the other SoP and address its criteria (s 11).

In short, compliance is evidentiary and procedural: produce contemporaneous clinical and service records that match the definition and factors in the instrument, show the temporal linkage required for clinical onset or worsening, and, where other SoPs are implicated, satisfy their criteria as well. The SoP itself supplies the medical yardstick, and compliance consists of meeting the instrument’s definitions and factor thresholds in the claims process authorised by the VEA and MRCA.