B46/1994 CRITICAL PROCEDURES FOR USING RMA SOPs PRIOR TO THEIR INCLUSION IN CCPS

External

Departmental Instruction

DATE OF ISSUE: 14 OCTOBER 1994

CRITICAL PROCEDURES FOR USING RMA SOPs PRIOR TO THEIR INCLUSION IN CCPS

It is absolutely essential that all Compensation staff, including Claims Assessors (CAs) and other delegates, fully understand this Procedural Instruction. It explains how to process disability claims using newly gazetted RMA SOPs which are not yet included in the current CCPS version. If you experience any difficulties or problems with this Instruction please contact Ron Mildenhall or Steve Peacock in the Procedures & Training Unit on 09.3668453 (W-B-PROJ1).

Gazettal of RMA SOPs

Gazettal of the RMA SOPs for the first seven conditions took place on Wednesday 14 September 1994. From the date of gazettal satisfaction of the contentions in the RMA SOPs is the only way that claims lodged on or after 1 June 1994 for RMA SOP conditions can be accepted. Failure to satisfy a contention means the claims must be rejected. Details of gazetted SOPs are in Appendix 1.

The RMA has indicated approval for 15 more conditions. Gazettal of the RMA SOPs for eight of these conditions took place on Wednesday 21 September 1994. The SOP Instruments for the remaining seven conditions are being prepared and are expected to be gazetted on 28 September 1994. Details are in Appendix 2.

A number of conditions have been submitted to the RMA and are currently under consideration. While the issue of SOPs for these conditions can be expected, it is not possible to say exactly when. Details of conditions currently being considered by the RMA but not yet covered by a SOP are at Appendix 3.

Distribution of RMA SOPs

Copies of the instruments for the seven conditions for which Statements of Principles have been approved by the RMA have been sent to Branches by the SOP Unit. The SOP Unit has also issued copies to the national headquarters of the peak Ex- Service Organisations (ESOs).

Branches are responsible for issuing copies of SOPs to all relevant officers in Compensation and other areas of the Branch. They should also issue copies to any organisation or individual that requests a copy. It is suggested that VAN, being the main contact area for both clients and ESOs would be best placed to do this. However, some distribution might be required of the CAs through normal client/advocate contact.

Gazettal of RMA Investigation

In the Gazette of 21 September 1994 was notification of investigations of Carcinoma of the Prostate and Gastro- Oesophageal Reflux Disease (smoking/alcohol contentions) by the RMA under 196B(4) of the Veterans' Entitlements Act. No claims lodged on or after 1 June 1994 for Carcinoma of the Prostate or death from that condition can be determined until this investigation has been finalised and a SOP gazetted.

Claims for Gastro-Oesophageal Reflux Disease or death from that condition can be determined as accepted, as a SOP for that condition has been gazetted on 21 September 1994. However, as there is an investigation of the smoking and alcohol contention notified, the only way a claim can be rejected is if one of the gazetted contentions is not satisfied and:

the veteran did not smoke or drink, or
the veteran states that smoking or alcohol are not causal factors , or
the veteran's smoking or alcohol habits are determined not to be related to service.

Otherwise these claims should remain undetermined until the RMA investigation is finalised.

Inclusion of RMA SOPs into CCPS

The broad redesign of CCPS to support the RMA SOPs has taken place recently. The CCPS system is currently being enhanced to supply this support. Although new rule bases and commentary are being written, the changes will not be finished by the next new release. In the meantime manual procedures are to be followed.

Procedures

Claims lodged before 1 June 1994

Choosing the Most Beneficial Contention

The Commission has given an undertaking to the ESOs that cases lodged before 1 June 1994 will not be disadvantaged following issue of the RMA SOPs. This means that when determining these cases CAs and other delegates will always investigate the most beneficial contention from either a Commission SOP or a RMA SOP. In CCPS this is being incorporated as the Most Beneficial Path (MBP).

This means that where a RMA SOP has been issued the system will be modified to indicate to the CA which is the MBP for each contention (either the Commission SOP contention or the RMA SOP contention) and automatically present this to the CA. Until the system is updated this will have to be done manually.

To assist this process, a comparison between RMA SOPs and Commission SOPs has been carried out to show the MBP to be used when deciding claims. The details for each RMA SOP condition are included in charts at Appendix 4.

Investigation, Decision and Reasons Using CCPS

Where Commission SOP contentions are more beneficial or essentially the same as RMA SOP contentions, CAs can use the current rule bases and system-produced investigative material. Where contentions are similar but the RMA SOP is more beneficial the current rule base and investigative material can be used but the questions and answers should be manipulated to result in a reflection of the RMA SOP. When a condition is accepted because of a more beneficial contention in a RMA SOP, the system-produced Reasons for Decisions will require little adjustment.

Reasons for acceptance in these cases will remain simple and straightforward. The heading of the contention and the basis of the acceptance are all that will show.

For example: The veteran is claiming Peptic Ulcer on the basis of taking NSAIDS for a service related disability within 14 days of onset of PU. He ceased taking NSAIDS 13 days prior to onset of the condition. This would not be accepted under the current rule base which has a seven day limit. However as the RMA SOP allows this contention the CA should answer the rule base question to allow acceptance.

If the RMA SOP contains a new contention this will have to be investigated outside of CCPS using manually produced investigative material. If this results in acceptance the Override facility should be used to accept the case and Reasons for Decision inserted manually.

Where a claim is rejected it is unnecessary to explain in detail to every claimant the different paths taken for each condition. Not only is it labour intensive but it adds a variety of different paragraphs that may be difficult to understand. When a pre 1 June 1994 condition is rejected after investigating the most beneficial contentions the reasons should simply say:

"I have considered all the evidence available, including Statements of Principles issued by the Repatriation Commission and the Repatriation Medical Authority. These Statements set out the ways in which a condition can be connected to service. I find that ... ".

The contention headings with findings should then be listed. Once CCPS has been updated the Reasons will appear differently.

Claims lodged on or after 1 June 1994

Differences between RMA SOPs and Commission SOPs

CAs should be aware of the differences between RMA SOPs and Commission SOPs which are included as rule bases in CCPS. The differences are indicated and commented on in the charts attached to Appendix 4 for each condition.

ICD Coding Conditions covered by a RMA SOP

It should be noted that RMA SOPs will not always cover the same range of ICD codes as Commission SOPs. For instance Gout previously only covered ICD Code 274 but the RMA SOP now also includes Code 984. Whereas Pathological Substance Abuse previously covered ICD Code 305, this is not covered by the RMA SOP on Psychoactive Substance Abuse or Dependence.

Claims Assessors should check carefully that the claimed condition is actually covered by the RMA SOP. If it is not, it cannot be determined under that SOP.

If the condition comes under a code which was not previously included in the Commission SOP it will have to be processed through CCPS as a non SOP condition. Condition specific Reasons will have to be inserted manually. This should be simple for acceptances but may prove more difficult for rejections. It may be easier to code it as "unspecified" for that condition(eg use code 274.9 for gout). It can then be processed using the support from CCPS in investigative material and Reasons.

Investigation, Decision and Reasons Using CCPS

Where the RMA issues a SOP for a condition for which there was no Commission SOP (eg Fractures) the claim will have to be processed as a non SOP on CCPS until the system is updated. Condition specific reasons are to be inserted manually. For all other conditions individual contentions will have to be compared.

Where RMA SOP contentions are essentially the same as Commission SOP contentions CAs can use the current rule bases and system-produced investigative material. Where contentions are similar but the RMA SOP is more or less beneficial the current rule base and investigative material can be used. However, the questions and answers must be manipulated to result in a reflection of the RMA SOP limitations.

The RMA SOPs contain many definitions of the terms contained in the contentions. Commentary is currently being written to explain the contentions. If a CA has any difficulty interpreting any contention in the RMA SOPs issued they should consult with their Team Manager. If it is still unclear then contact Dave Goldrick (C-B-RD-5) in Compensation Operations Section, Central Office or phone 06.2896580. Mr Goldrick is coordinating development of the Rule bases and Commentary for the RMA SOPs and liases with the Department's SOP Development Unit.

The system is being redesigned with regard to reasons for rejection and CAs should follow the outline provided to keep consistency with future system-produced Reasons. An example copy of the Reasons for a rejection is at Appendix 5. Paragraphs for use in Reasons are at Appendices 6 and 7.

The main points included in this example are:

The Law paragraphs have been reduced to merely state the standard of proof that applies. The definitions of the Standard of Proof, War Caused Injuries, Defence Caused Injuries, War Caused Death and Defence Caused Death have been dropped from the Explanatory Attachment.

A new heading and paragraph on the Statements of Principles has been added. This paragraph refers to further detail on what the RMA and Statement of Principles are in the Explanatory Attachment. A new Section of the Explanatory Attachment on this subject has been added.

The introductory paragraphs on each rejected condition explaining what it is and how it can be accepted has been dropped. Instead a generic paragraph has been added under the heading "Reasons for Rejected Conditions". This indicates the CA has considered all the factors contained in the SOPs. It also indicates that these are listed in the Explanatory Attachment.

The Explanatory Attachment contains a short section on each rejected condition that states what it is and what contentions are listed in the SOP. It does not go into detail on the contentions. It suggests the claimant obtain a copy of the SOP if they want further detail.

If aggravation cannot be considered because the condition developed after service a general paragraph is added to this affect.

Any contention which has been fully investigated has a heading and details of the finding.

Contentions for which there is no history are grouped together under the heading "Other Factors". A few sentences indicate the findings for all these contentions.

Contentions where there is no evidence to suggest they could apply are grouped together and dealt with in one general sentence.

Any contention put forward by the claimant is dealt with by a paragraph at the end of the contentions.

The final paragraph includes reference to the SOPs.

Reasons generated will need to be checked carefully. Amendments may need to be added in accordance with this outline to cover all RMA SOP contentions. New paragraphs as outlined above that are included in the attachment should be inserted into Glossaries for ease of use.

Future SOPs

The Procedures & Training Unit will issue further updates on MBP for RMA SOP conditions as they are gazetted.

A W ASHFORD

NATIONAL PROGRAM DIRECTOR

BENEFITS

APPENDIX 1

RMA STATEMENTS OF PRINCIPLES GAZETTED ON 14 SEPTEMBER 1994:

Malignant Neoplasm of the Lung

Depressive Disorder

Psychoactive Substance Abuse or Dependence

Gout

Peptic Ulcer Disease

Fracture

Ingrown Toenail

APPENDIX 2

RMA STATEMENTS OF PRINCIPLES GAZETTED ON 21 SEPTEMBER 1994:

Sensorineural Hearing Loss

Post Traumatic Stress Disorder

Chronic Airflow Limitation

Malignant Neoplasm of the Pancreas

Malignant Neoplasm of the Stomach

Gastro Oesophageal Reflux Disease

Inguinal Hernia

Tinea

RMA STATEMENTS OF PRINCIPLES EXPECTED TO BE GAZETTED ON 28 SEPTEMBER 1994:

Reiter's Syndrome

Acute Myeloid Leukaemia

External Burns

Cholelithiasis

Gunshot Wound

Hepatitis A

External Bruises and External Contusions

CONDITIONS GAZETTED ON 21 SEPTEMBER 1994 FOR INVESTIGATION BY THE RMA UNDER S196B(4) OF VEA:

Carcinoma of the Prostate

Gastro-Oesophageal Reflux Disease (smoking/alcohol contentions)

APPENDIX 3

CONDITIONS CURRENTLY BEING CONSIDERED BY THE RMA BUT SOP NOT YET APPROVED:

Diverticular Disease

Anxiety State

Asthma

Haemorrhoids

Varicose Veins

Hepatitis B

Hepatitis C

Hepatitis D

Hepatitis E

Chicken Pox

Herpes Zoster

Analgesic Nephropathy

Mesothelioma

Sprains and Strains

APPENDIX 4

COMPARISON OF COMMISSION SOPS AND RMA SOPS SHOWING MOST BENEFICIAL PATH

PSYCHOACTIVE SUBSTANCE ABUSE OR DEPENDENCE

ICD CODE Commission - 305.0, 303.9 (305.0 - Pre June, non dependent abuse only)

RMA - 303, 304 (only in post June cases)

NB - ANY SUBSTANCE OTHER THAN ALCOHOL IS NEW - RMA SOP TO BE FOLLOWED

Reasonable Hypothesis

COMMISSION SOP

RMA SOP

MOST BENEFICIAL PATH (MBP)

COMMENTS

1. Developed pattern of abuse on service as a result of stress and maintains pattern of abuse post service

Experienced stressful event prior to onset of pattern of abuse and maintains abuse post service

RMA SOP most beneficial

RMA SOP includes other substances apart from alcohol. Stressful event and onset of pattern of abuse can occur post service.

2. Has a psychiatric condition which has as a feature substance abuse

Had psychiatric condition prior to onset of abuse

RMA SOP most beneficial

RMA SOP only requires a psychiatric condition, does not have to have substance abuse as a feature

Aggravation

Experienced stressful event prior to worsening of pattern of abuse and maintains abuse post service

RMA SOP most beneficial - new

Had psychiatric condition prior to worsening of abuse

RMA SOP most beneficial - new

Inability to obtain appropriate clinical management for abuse

RMA SOP most beneficial - new

PSYCHOACTIVE SUBSTANCE ABUSE OR DEPENDENCE

ICD CODE Commission - 305.0, 303.9 (305.0 - Pre June, non dependent abuse only)

RMA - 303, 304 (only in post June cases)

NB - ANY SUBSTANCE OTHER THAN ALCOHOL IS NEW - RMA SOP TO BE FOLLOWED

Balance of Probabilities

COMMISSION SOP

RMA SOP

MOST BENEFICIAL PATH (MBP)

COMMENTS

Experienced a severely stressful event prior to onset of pattern of abuse and maintains abuse post service

RMA SOP most beneficial - new

Difference between RMA SOP reasonable hypothesis and balance of probabilities is the addition of the term severely stressful event. This is defined as a psychologically distressing event that is outside of the range of usual human experiences.(eg bombing and torture but not simple bereavement or marital conflict)

RMA SOP includes other substances apart from alcohol . Stressful service and onset of pattern of abuse can occur post service.

2. Has a psychiatric condition which has as a feature substance abuse

Had psychiatric condition prior to onset of abuse

RMA SOP most beneficial

RMA SOP only requires a psychiatric condition, does not have to have substance abuse as a feature

Aggravation

Experienced a severely stressful event prior to worsening of pattern of abuse and maintains abuse post service

RMA SOP most beneficial - new

(note the term severely stressful event above)

Had psychiatric condition prior to worsening of abuse

RMA SOP most beneficial - new

Inability to obtain appropriate clinical management for abuse

RMA SOP most beneficial - new

DEPRESSIVE DISORDERS

ICD CODES

Commission - 296.2, 300.4, 311

RMA 296.3, 300.4, 311

(Note: ICD Code 296.2 is listed in Instrument for RMA SOP but it is not applicable due to definition of depressive disorder in SOP)

Reasonable Hypothesis

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1. POW	POW	Same
2. Developed on service, symptoms continuing	Experience of a stressor within two years prior to onset	RMA SOP most beneficial	RMA SOP allows depressive disorder to develop after service. Stressor does not have to have occurred on service
3. Condition is secondary to a major or life threatening illness causally related to service	Major illness or injury within two years prior to onset	RMA SOP most beneficial	Allows increased length of time between illness, injury and onset. Includes injuries
4.	Psychiatric condition within two years prior to onset of depressive disorder	RMA SOP most beneficial - new

Aggravation

5.	Experience of a stressor within two years prior to worsening	RMA SOP most beneficial - new
6.	Major illness or injury within two years prior to worsening	RMA SOP most beneficial - new
7.	Psychiatric condition within two years prior to worsening of depressive disorder	RMA SOP most beneficial - new
8.	Inability to obtain appropriate clinical management	RMA SOP most beneficial - new

DEPRESSIVE DISORDERS

ICD CODES

Commission - 296.2, 300.4, 311

RMA 296.3, 300.4, 311

(Note: ICD Code 296.2 is listed in Instrument for RMA SOP but it is not applicable due to definition of depressive disorder in SOP)

Balance of Probabilities

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1 Developed on service, symptoms continuing	Experience of a stressor within one year prior to onset	RMA SOP most beneficial	RMA SOP allows depressive disorder to develop after service. Stressor does not have to have occurred on service
2. Condition is secondary to a major or life threatening illness causally related to service	Major illness or injury within one year prior to onset	RMA SOP most beneficial	Allows increased length of time between illness, injury and onset. Includes injuries
3.	Psychiatric condition within one year prior to onset of depressive disorder	RMA SOP most beneficial - new

Aggravation

4.	Experience of a stressor within one year prior to worsening	RMA SOP most beneficial - new
5.	Major illness or injury within one year prior to worsening	RMA SOP most beneficial - new
6.	Psychiatric condition within one year prior to worsening of depressive disorder	RMA SOP most beneficial - new
7.	Inability to obtain appropriate clinical management	RMA SOP most beneficial - new

FRACTURE

ICD CODES

RMA 733.1, 800 - 829

No previous Commission ICD Code

Reasonable Hypothesis

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1.Nil	Trauma at site and at time of fracture	RMA	ALL OF THESE CONTENTIONS ARE NEW UNDER THE RMA SOP,
2.Nil	Repetitive physical stress	RMA	THEREFORE, THE MOST BENEFICIAL PATH FOR ALL IS
3.Nil	Paget's disease	RMA	THE RMA SOP
4.Nil	Osteoporosis or osteomalacia	RMA
5.Nil	A mycotic, suppurative, or syphilitic infection of the bone	RMA
6.Nil	Malignant neoplasm	RMA
7.Nil	A benign tumour	RMA

Aggravation

All of the above except for repetitive stress are included for worsening. A further addition to these is - Inability to obtain appropriate clinical management for the fracture.

Balance of Probabilities

Under the balance of probabilities the same contentions for occurrence and aggravation apply, making the most beneficial path the RMA SOP.

GOUT

ICD CODES

Commission - 274

RMA - 274 & 984

Reasonable Hypothesis

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1. Multiple Myeloma 6 mths	Multiple myeloma 6 mths	Same
2. Leukemia 6 mths	Active systemic leukemia 6 mths	Same
3. Active systemic malignancy 6 mths	Myeloid metaplasia 6 mths	RMA SOP most beneficial - new	active systemic malignancy, myeloid metaplasia and polycythemia vera
4. Nil	Polycythemia vera 6 mths	RMA SOP most beneficial - new	are disorders of a similar nature and so have been grouped together
5. Nil	Lead nephropathy	RMA SOP most beneficial - new	for purposes of identifying the MBP

6. Pernicious anaemia 6 mths	Not include in new SOPs	Commission SOP most beneficial	Not considered a causal factor by RMA
7. Infectious mononucleosis 6 mths	Not included in new SOPs	Commission SOP most beneficial	Not considered a causal factor by RMA
8. Thiazide diuretics 4 weeks	Thiazide diuretics 4 weeks	Same
9. Nicotinic acid 4 weeks	Nicotinic acid 4 weeks	Same
10. Pyrazinamide 4 weeks	Pyrazinamide 4 weeks	Same
11. Ethambutol 4 weeks	Ethambutol 4 weeks	Same
12. Chronic renal disease	Not included in new SOPs	Commission SOP most beneficial	Not considered a causal factor by RMA

GOUT (reasonable hypothesis - continued)

Aggravation

13. Nil	Presence of one of the following diseases within the six months prior to worsening of condition; active systemic leukaemia, myeloid metaplasia, polycythaemia vera, multiple myeloma	RMA SOP most beneficial - new
14. Nil	administration of one of the following within 28 days prior to worsening of condition; thiazide diuretics, acetyl-salicylic acid (aspirin), ethambutol	RMA SOP most beneficial - new
15. Nil	Lead nephropathy prior to worsening of condition	RMA SOP most beneficial - new
16. Nil	Inability to obtain appropriate clinical management for condition	RMA SOP most beneficial - new

GOUT

ICD CODES

Commission - 274

RMA - 274 & 984

Balance of Probabilities

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1.Nil	Multiple myeloma 6 mths	Same
2.Nil	Active systemic leukemia 6 mths	Same
3. Nil	Myeloid metaplasia 6 mths	RMA SOP most beneficial - new	active systemic malignancy, myeloid metaplasia and polycythemia vera
4. Nil	Polycythemia vera 6 mths	RMA SOP most beneficial - new	are disorders of a similar nature and so have been grouped together
5. Nil	Lead nephropathy	RMA SOP most beneficial - new	for purposes of identifying the MBP

6. Nil	Not include in new SOPs	Commission SOP most beneficial	Not considered a causal factor by RMA
7. Nil	Not included in new SOPs	Commission SOP most beneficial	Not considered a causal factor by RMA
8. Nil	Thiazide diuretics 4 weeks	Same
9. Nil	Nicotinic acid 4 weeks	Same
10. Nil	Pyrazinamide 4 weeks	Same
11. Nil	Ethambutol 4 weeks	Same
12. Nil	Not included in new SOPs	Commission SOP most beneficial	Not considered a causal factor by RMA

GOUT (balance of probabilities continued)

Aggravation

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
13. Nil	Presence of one of the following diseases within the six months prior to worsening of condition; active systemic leukaemia, myeloid metaplasia, polycythaemia vera, multiple myeloma	RMA SOP most beneficial - new
14. Nil	administration of one of the following within 28 days prior to worsening of condition; thiazide diuretics, acetyl-salicylic acid (aspirin), ethambutol	RMA SOP most beneficial - new
15. Nil	Lead nephropathy prior to worsening of condition	RMA SOP most beneficial - new
16. Nil	Inability to obtain appropriate clinical management for condition	RMA SOP most beneficial - new

INGROWN TOENAIL

ICD CODES

Commission - 703.0

RMA - 703.0

Reasonable Hypothesis

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1. Poor footwear developed on service	Poor footwear within two days prior to onset	RMA SOP most beneficial	RMA SOP allows condition to develop post service
2. Poor hygiene developed on service	Poor hygiene within two days prior to onset	RMA SOP most beneficial	RMA SOP allows decision to develop post service
3. Developed as a result of ill fitting footwear during service	Wearing ill fitting footwear within two days prior to onset	RMA SOP most beneficial	RMA SOP allows condition to develop post service
4. Deformity of toe or toenail causally related to service contributing to ingrown toenail	Deformity of the toe or toenail within two days prior to onset of ingrown toenail	Commission SOP most beneficial	Commission SOP does not put 2 day limit on onset

Aggravation

5	Poor foot care within two days prior to worsening	RMA SOP is most beneficial - new
6.	Poor foot hygiene within two days prior to worsening	RMA SOP is most beneficial - new
7.	Wearing ill fitting footwear within two days prior to worsening	RMA SOP is most beneficial - new
8.	Deformity of toe or toenail within two days prior to worsening of ingrown toenail	RMA SOP is most beneficial - new
9.	Inability to obtain appropriate clinical management for ingrown toenail	RMA SOP most beneficial - new

INGROWN TOENAIL

ICD CODES

Commission 703.0

RMA - 703.0

Balance of Probability

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1.Nil	Poor footwear within two days prior to onset	RMA SOP most beneficial - new
2.Nil	Poor hygiene within two days prior to onset	RMA SOP most beneficial - new
3. Developed as a result of ill fitting footwear during service	Wearing ill fitting footwear within two days prior to onset	RMA SOP most beneficial	RMA SOP allows condition to develop post service
4. Deformity of toe or toenail causally related to service contributing to ingrown toenail	Deformity of the toe or toenail within two days prior to onset of ingrown toenail	Commission SOP most beneficial	Commission SOP does not put 2 day limit on onset

Aggravation

5	Poor foot care within two days prior to worsening	RMA SOP is most beneficial - new
6.	Poor foot hygiene within two days prior to worsening	RMA SOP is most beneficial - new
7.	Wearing ill fitting footwear within two days prior to worsening	RMA SOP is most beneficial - new
8.	Deformity of toe or toenail within two days prior to onset of ingrown toenail	RMA SOP is most beneficial - new
9.	Inability to obtain appropriate clinical management for ingrown toenail	RMA SOP most beneficial - new

MALIGNANT NEOPLASM OF THE LUNG

ICD CODES

Commission - 162

RMA - 162

Reasonable Hypothesis

COMMISSION SOP

RMA SOP

MOST BENEFICIAL PATH (MBP)

COMMENTS

1. Smoking

- 5 pack year smoking habit

2. Has asbestosis

3. Exposure to mustard gas

4. Coke oven

5. Radon exposure

6. Hiroshima and Nagasaki

Smoking

- cigarettes

- pipe

- cigars

- passive smoking

Exposure to respirable asbestos fibres

Same

Coke oven

Nil

Hiroshima and Nagasaki

RMA SOP is most beneficial path

Use whichever is in system

RMA SOP most beneficial

Commission SOP most beneficial

RMA SOP is most beneficial path

Easing of smoking requirement from any smoking habit of 5 pack years to half pack year prior to clinical onset for, malignant neoplasia of lung and 3 pack years for adenocarcinoma of lung.

Also included in the RMA SOPS are passive smoking, cigar smoking and pipe smoking for non typical cancers

Claimant does not need to have contracted asbestosis, but has to have been exposed to respirable asbestos.

Time limit reduced to 180 days

Not considered causal under RMA SOP

RMA has reduced allowable distance from epicentre from 25km to 4km

MALIGNANT NEOPLASM OF THE LUNG

Reasonable Hypothesis (continued)

COMMISSION SOP

RMA SOP

MOST BENEFICIAL PATH (MBP)

COMMENTS

7 Other lung diseases

8 Nil

9. Nil

10.Nil

11.Nil

Other lung diseases.

Using insecticides or herbicides

Care of birds as an occupationa;l requirement for at least year prior to the clinical onset of malignant neoplasm of the lung

Receipt of a course of therapeutic radiation of at least three years prior to the person seeking treatment for malignant neoplasm of the lung

Inability to obtain appropriate clinical management for the neoplasm of the lung

RMA SOP MBP for pneumonia & TB. RMA SOP is also MBP for Chronic bronchitis.

Either can be used for emphysema and asthma, they are the same for both types of SOPs.

Commission SOP is MBP for Pulmonary fibrosis.

RMA SOP most beneficial - new

RMA SOP most beneficial- new

CA needs to be aware that RMA SOP only includes those lung diseases listed, no others can be accepted under the RMA SOP.

Aggravation only

MALIGNANT NEOPLASM OF THE LUNG

ICD CODES

Commission - 162

RMA - 162

Balance of Probabilities

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1. Smoking - 5 pack year smoking habit	Smoking - cigarettes - pipe - cigars - passive smoking	RMA SOP most beneficial for malgnant neoplasia of lung Same for adenocarcinoma of lung new new new	RMA SOP is most beneficial path. Ease of smoking requirement from any smoking habit of 5 pack years to two pack years for , malignant neoplasia of lung. Also included in the RMA SOPS are passive smoking, cigar smoking and pipe smoking for non typical cancers
2. Has asbestosis	Exposure to respirable asbestos while working with it	RMA SOP most beneficial	Claimant does not need to have asbestosis but needs to have been exposed while being the person working with it
3. Mustard gas	Mustard gas	Same
4. Coke oven	Not included in RMA SOP	Commission SOP most beneficial	Not considered causal under RMA SOP
5. Radon	Not included in RMA SOP	Commission SOP most beneficial	Not considered causal under RMA SOP
6. Hiroshima and Nagasaki	Not included in RMA SOP	Commission SOP most beneficial	Not appropriate for balance of probability
7. Other lung diseases	Not included in RMA SOP	Commission SOP most beneficial	Not considered causal under RMA SOP
8. Nil	Using insecticides or herbicides	RMA SOP most beneficial - new

MALIGNANT NEOPLASM OF THE LUNG

Balance of Probabilities (continued)

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
9. Nil	Inability to obtain appropriate clinical management for the neoplasm of the lung	RMA SOP most beneficial - new	Aggravation only

PEPTIC ULCER DISEASE

ICD CODES

Commission - 531 - 534

RMA - 531 - 534

Reasonable Hypothesis

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1. POW	POW	Same
2. Smoking 1/2 pack year	Smoking 10 per day	Same	at least 1/2 pack per day at onset is the same as at least 10 per day at onset
3. High dose oral corticosteroids within seven days prior to onset (50mgm/day)	Not included in RMA SOP	Commission SOP is most beneficial	Not considered causal under RMA
4. Aspirin at onset or non steriodal anti inflammatory drugs within seven days prior to onset	Non steroidal anti inflammatory drugs within 14 days prior to onset (includes aspirin)	RMA SOP is most beneficial	Aspirin is included in NSAIDs. RMA SOP increases time from treatment to onset to 14 days
5. Severe stressful service and has symptoms continuing from that time	Severely stressful circumstances for at least six months immediately preceding the onset	Both SOPs need to be looked at to determine the most beneficial path to fit the circumstances of the case	While these are similar either could be the MBP depending upon the case. RMA SOP allows development post service
6	Helicobacter pylori infection prior to onset	RMA SOP - new	If not established by testing, infection may be presumed if the person was for at least six months living in overcrowded conditions and shared eating facilities and utensils and had limited opportunities for bathing

PEPTIC ULCER DISEASE (Reasonable hypothesis - continued)

Aggravation

7.	Smoking at least 10 per day at time of worsening of condition	RMA SOP most beneficial - new
8.	Non steroidal anti inflammatory drugs within 14 days prior to worsening of condition	RMA SOP most beneficial - new
9.	Experience of stressful circumstances for at least six months immediately prior to worsening of condition	RMA SOP most beneficial - new
10.	Inability to obtain appropriate clinical management of disease	RMA SOP most beneficial - new

PEPTIC ULCER DISEASE

ICD CODES

Commission - 531 - 534

RMA - 531 - 534

Balance of probabilities

COMMISSION SOP	RMA SOP	MOST BENEFICIAL PATH (MBP)	COMMENTS
1. Smoking at least 1/2 pack year	Smoking 10 per day	Same	At least 1/2 pack per day at onset is the same as at least 10 per day at onset
2. High dose oral corticosteroids within seven days prior to onset (50mgm/day) within 7 days prior	Not included in RMA SOP	Commission SOP is most beneficial	Not considered causal under RMA
3. Aspirin at onset or non steriodal anti inflammatory drugs within seven days prior to onset	Non steroidal anti inflammatory drugs within seven days prior to onset (includes aspirin)	RMA SOP is most beneficial for aspirin. Same for other NSAIDs	Aspirin is covered by the term NSAIDs, therefore RMA SOP increases time limit from treatment to onset to 7 days
4. Severe stressful service and has symptoms continuing from that time	Severely stressful circumstances for at least six months immediately preceding the onset	Both SOPs need to be looked at to determine the most beneficial path to fit the circumstances of the case	While these are similar either could be the MBP depending on the case. RMA SOP allows development post service
5	Helicobacter pylori. for five years prior to onset	RMA SOP - new	Infection may be presumed if the person was for at least five years living in overcrowded conditions and shared eating facilities and utensils and had limited opportunities for bathing

PEPTIC ULCER DISEASE (Balance of probabilities - continued)

Aggravation

6	Smoking at least 10 per day at time of worsening of condition	RMA SOP most beneficial - new
7.	Non steroidal anti inflammatory drugs within seven days of worsening of condition	RMA SOP most beneficial - new
8.	Experience of severely stressful circumstances for at least six months immediately preceding the worsening of the condition	RMA SOP most beneficial - new
9.	Inability to obtain appropriate clinical management for condition	RMA SOP most beneficial - new

APPENDIX 5

EXAMPLE OF REASONS FOR DECISION FOR RMA SOP CONDITION

The Law

The law states that for a claim to be accepted the disability must be related to operational war service.

When considering operational service I must accept the claim if there is a reasonable hypothesis connecting the disability with this service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable. These factors are the only ways I can relate a condition to service.

I cannot accept a condition as being related to service unless it meets one of the factors set out in the Statement of Principles for that condition. However, I must be satisfied beyond reasonable doubt that a factor does not exist before the claim can be rejected. Information about the RMA is contained in the Explanatory Attachment to this letter.

Reasons for Rejected Conditions

I have considered the evidence that is relevant to this claim. This includes the details of service, the history of the claimed condition{s} and the factors in the Statement{s} of Principles that can cause or aggravate these conditions {this condition}. A list of these factors is contained in the Explanatory Attachment.

I find that:

Gout

Thiazide diuretics

Although gout may have been caused by the taking of thiazide diuretics, this drug was taken for hypertension which is not due to operational service.

Salicyclic acid (aspirin)

Aspirin can be considered as a cause of gout if the aspirin was taken in the 28 days before the symptoms of gout first appeared. These conditions were not met in this case.

Other factors

There is no history of taking nicotinic acid, pyrazinamide and ethambutol. There is no history of lead nephropathy.

The evidence before me indicates that the other factors that can cause gout, contained in the Statement of Principles, do not apply in this case.

Gout can only be aggravated by factors that are due to service if the symptoms or signs of gout developed before the end of service. In this case, as gout developed after service, aggravation of gout cannot be considered.

I have noted your claim that gout was caused by drinking alcohol but this is not a factor listed in the Statement of Principles because it is not supported by sound medical-scientific evidence. Therefore gout cannot be related to service by this factor.

The circumstances of this case do not satisfy the Statement of Principles issued by the RMA in respect of Gout. As a result I find that all the evidence does not raise a reasonable hypothesis connecting Gout and operational service. I am therefore unable to accept it as war caused.

RIGHT OF APPEAL

If you are not satisfied with any part of my decision you can ask the Veterans' Review Board (VRB) to consider the case. You would have to do this in writing. There are time limits on lodging an application to the VRB and this is explained in the Explanatory Attachment to this letter.

HELP AVAILABLE

Help can be obtained in dealing with any part of this decision, the reasons for it and appeal rights by contacting:

Claims Assessor, as per contact details above.
an ex-service organisation - their addresses and telephone numbers are listed in the telephone book.

Yours sincerely,

Claims Assessor

Commonwealth Department of

Veterans' Affairs

EXPLANATORY ATTACHMENT

TO ADVICE OF DECISION

Claimant Details

Surname	Given Names		DVA File Number
Veteran		John		X200722

This attachment is provided for further explanation of information and terms contained in the reasons for decision advice letter. It is not necessary for you to read it, but you should retain it for future reference whenever you need to know more information about the decision, your rights and entitlements.

Table of Contents

Page

Repatriation Medical Authority — 1

Statements of Principle — 1

Gout — 1

Malignant Neoplasm of the Lung — 2

Appeal Rights to the VRB — 2

Freedom of Information — 3

REPATRIATION MEDICAL AUTHORITY

The Repatriation Medical Authority (RMA) is an independent body of five eminent medical specialists who have been appointed by the Minister for Veterans' Affairs after consultation with the ex-service community.

The RMA was established to implement initiatives relating to disability and death claim decisions which came out of the 1994/95 Budget .

These initiatives were designed to ensure a more equitable and consistent system of determining claims for veterans and their dependents. The RMA has the task of making decisions, based on sound medical-scientific evidence, on what factors related to service must exist to establish a causal connection between particular diseases, injuries or death and service. These decisions are published as Statements of Principles.

STATEMENTS OF PRINCIPLES

Statements of Principles are legislative instruments which must be notified in the Commonwealth Gazette and be tabled in both Houses of the Parliament. Once allowed these Statements of Principles are binding on the Repatriation Commission, the Veterans' Review Board and the Administrative Appeals Tribunal.

A separate statement will be issued for every claimable condition. This is being done progressively and will be an ongoing task. They contain the detail of what factors the RMA has indicated must exist to establish a causal connection to service. The statements are based on sound medical-scientific evidence and are reviewable to ensure that this evidence remains current.

Reviews of the Statements of Principles will be carried out by the Specialist Medical Review Council (SMRC)

Listed below is an outline of the factors in the Statement(s) of Principles that apply(ies) in this case. If you wish to obtain a copy of the full Statement of Principles containing all details and definitions of the following factors please contact the Department.

GOUT

Gout is caused by hyperuricaemia. This is an excess of urate in the blood and tissues which can lead to the deposit of sodium urate crystals in the joints and elsewhere. It is these deposits which cause the acute attack of gout and other features of the disease.

The RMA has issued a Statement of Principles that states what factors must exist to establish a reasonable hypothesis connecting gout and operational service. These factors, which must be due to operational service, are outlined below:

Factors that can cause or aggravate gout :

Active systemic leukaemia, myeloid metaplasia, polycythemia vera, multiple myeloma or lead nephropathy.

Treatment with thiazide diuretics, salicyclic acid (aspirin), nicotinic acid, pyrazinamide or ethambutol.

Factors that can aggravate gout :

the inability to obtain appropriate clinical management for gout.

Malignant Neoplasm of the lung

The RMA has issued a Statement of Principles that states what factors must exist to establish a reasonable hypothesis connecting malignant neoplasm of the lung and operational service. These factors, which must be due to operational service, are outlined below:

Factors that can cause malignant neoplasm of the lung :

Smoking specified levels of cigarettes, cigars and pipe tobacco or passive smoking.

Occupational exposure to respirable asbestos fibres, mustard gas, insecticides or herbicides

Working with coke ovens, occupational care of birds, exposure to atomic radiation in Japan, a course of therapeutic radiation, asthma, chronic bronchitis, emphysema, pneumonia or pulmonary tuberculosis

Factors that can aggravate malignant neoplasm of the lung

the inability to obtain appropriate clinical management for malignant neoplasm of the lung.

Appeal Rights to the VRB

If you are not satisfied with the decision made on the claim for acceptance of a disability as service related you can ask the Veterans' Review Board (VRB) to review the Commission delegate's decision.

How to Apply

You must apply in writing and your application must be sent to the Department of Veterans' Affairs.

You can apply just by writing a letter or you can fill out a specific VRB application form. These forms can be obtained from the Department of Veterans' Affairs or may be available from ex-service organisations.

If you wish, you can state in your application the reasons why you are dissatisfied with the delegate's decision.

Time limits for applying to the VRB

If you want to apply to the VRB to review a decision, your application must be received by the Department of Veterans' Affairs within 12 months from when you received the letter telling you of the delegate's decision on whether or not a disability was service related.

Although you have 12 months to lodge a VRB application in this matter, if you lodge the application within 3 months of receiving the delegate's decision, the VRB can backdate their decision further if they accept the disability or death as war-caused or defence-caused. You should therefore try to get the VRB application in to the Department of Veteran's Affairs within the 3 month period.

If you want to apply to the VRB to review the decision that a veteran's death was war-caused or that a member's death was defence-caused, your application must be received by the Department of Veterans' Affairs within 12 months from when you received the letter telling you of the delegate's decision.

If the VRB varies the delegate's decision, it can only approve maximum benefits if you lodged the VRB application within 3 months of receiving the delegate's decision. Therefore, although you have 12 months to lodge the VRB application, you should try to get the VRB application in to the Department of Veteran's Affairs within the 3 month period.

What happens when you lodge a VRB application?

After receiving your application the Department of Veterans' Affairs will prepare a report of the relevant evidence contained in the departmental files. A copy of the report will then be sent to you (and your representative if you have chosen one) and you will be asked to send any written comments on the case to the Department of Veterans' Affairs. When your comments are received, all the records will be sent to the VRB.

The VRB will then set a time and date to hear the case. There may be a delay before the case can be listed for hearing but the VRB will send you a letter telling you about the hearing arrangements.

At the hearing you will be able to discuss the case with the members of the VRB.

The VRB may agree or disagree with the delegate's decision. If they disagree with the delegate's decision on a disability entitlement matter, that is, they decide that a disability is war-caused or defence-caused, they often send the case to the Department of Veterans' Affairs to decide the rate of pension to be paid.

However, it is unusual for the VRB to disagree with the delegate's decision unless there is fresh applicable supportive evidence. Ex-service Organisations can offer advice regarding evidence required and assist veterans in presenting their case to the VRB

The VRB will send you a letter telling you about their decision and your appeal rights.

Freedom of Information

Under the FOI Act you may look at or get a copy of documents that are held by the Department of Veterans' Affairs. This includes the records in your departmental files and any printed material such as departmental policies and instructions.

Usually you would have to pay an application fee to get access to the documents you would like to see. However, if your FOI request was to do with a claim for pension or other benefit, then you would not have to pay any fee or other charge.

If you want further information about getting access to documents under the FOI Act, ring or write to your nearest office of the Department of Veterans' Affairs.

APPENDIX 6

REPLACEMENT PARAGRAPHS FOR REASONS INVOLVING RMA SOPS

DISABILITY CLAIM

Operational Service Only

The Law

The law states that for a claim to be accepted the disability must be related to operational war service.

When considering operational service I must accept the claim if there is a reasonable hypothesis connecting the disability with this service.

Statement of Principles

Eligible Service Only

The Law

The law states that for a claim to be accepted the disability must be related to eligible war service.

When considering the evidence I must be reasonably satisfied that on the balance of probabilities the disability is caused by eligible war service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a connection to service to be probable. These factors are the only ways I can relate a condition to service.

I cannot accept a condition as being related to service unless it meets one of the factors set out in the Statement of Principles for that condition. However, I must be reasonably satisfied that the factor exists before the claim can be accepted. Information about the RMA is contained in the Explanatory Attachment to this letter.

Defence Service Only

The Law

The law states that for a claim to be accepted the disability must be related to eligible defence service.

When considering the evidence I must be reasonably satisfied that on the balance of probabilities the disability is caused by eligible defence service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a connection to service to be probable. These factors are the only ways I can relate a condition to eligible defence service.

Operational and eligible service

The Law

The law states that for a claim to be accepted the disability must be related to operational or eligible war service. Diferent standards of proof apply to these two types of service.

When considering operational service I must accept the claim if there is a reasonable hypothesis connecting the disability with this service. When considering eligible service I must be reasonably satisfied that on the balance of probabilities the disability is war caused.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable or for a connection to service to be probable.. These factors are the only ways I can relate a condition to service.

I cannot accept a condition as being related to service unless it meets one of the factors set out in the Statement of Principles for that condition. However, for operational service I must be satisfied beyond reasonable doubt that a factor does not exist before the claim can be rejected. For eligible service I must be reasonably satisfied that the factor exists before the claim can be accepted. Information about the RMA is contained in the Explanatory Attachment to this letter.

Eligible and defence service

The Law

The law states that for a claim to be accepted the disability must be related to eligible war or defence service.

When considering the evidence I must be reasonably satisfied that on the balance of probabilities the disability is caused by eligible war or defence service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a connection to service to be probable. These factors are the only ways I can relate a condition to eligible war or defence service.

Operational and defence service

The Law

The law states that for a claim to be accepted the disability must be related to operational or eligible defence service. Different standards of proof apply to these two types of service.

When considering operational service I must accept the claim if there is a reasonable hypothesis connecting the disability with this service. When considering eligible defence service I must be reasonably satisfied that on the balance of probabilities the disability is caused by defence service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable or for a connection to service to be probable.. These factors are the only ways I can relate a condition to service.

I cannot accept a condition as being related to service unless it meets one of the factors set out in the Statement of Principles for that condition. However, for operational service I must be satisfied beyond reasonable doubt that a factor does not exist before the claim can be rejected. For eligible defence service I must be reasonably satisfied that the factor exists before the claim can be accepted. Information about the RMA is contained in the Explanatory Attachment to this letter.

Operational, eligible and defence service

The Law

The law states that for a claim to be accepted the disability must be related to operational or eligible war or defence service. Different standards of proof apply to these types of service.

When considering operational service I must accept the claim if there is a reasonable hypothesis connecting the disability with this service. When considering eligible war or defence service I must be reasonably satisfied that on the balance of probabilities the disability is caused by defence service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable or for a connection to eligible war or defence service to be probable.. These factors are the only ways I can relate a condition to service.

I cannot accept a condition as being related to service unless it meets one of the factors set out in the Statement of Principles for that condition. However, for operational service I must be satisfied beyond reasonable doubt that a factor does not exist before the claim can be rejected. For eligible war or defence service I must be reasonably satisfied that the factor exists before the claim can be accepted. Information about the RMA is contained in the Explanatory Attachment to this letter.

Death Claim

Operational service only

The law states that for the death of {+VeteranForename,M} {+VeteranSurname,M} to be accepted as service related, the cause of death must be related in some way to operational war service

When considering operational service I must accept the claim if there is a reasonable hypothesis connecting the death with this service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as causing death related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable. These factors are the only ways I can relate death from a condition to service.

I cannot accept death as being related to service unless it meets one of the factors set out in the Statement of Principles for the condition causing death. However, I must be satisfied beyond reasonable doubt that a factor does not exist before the claim can be rejected. Information about the RMA is contained in the Explanatory Attachment to this letter.

Eligible service

The law states that for the death of {+VeteranForename,M} {+VeteranSurname,M} to be accepted as service related, the cause of death must be related in some way to eligible war service.

When considering the evidence I must be reasonably satisfied that the death is caused by eligible war service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as causing death related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a connection to service to be probable. These factors are the only ways I can relate death from a condition to service.

I cannot accept death as being related to service unless the evidence meets one of the factors set out in the Statement of Principles for the condition causing death. However, I must be reasonably satisfied that the factor exists before the claim can be accepted. Information about the RMA is contained in the Explanatory Attachment to this letter.

Defence service

The law states that for the death of {+VeteranForename,M} {+VeteranSurname,M} to be accepted as service related, the cause of death must be related in some way to eligible defence service.

When considering the evidence I must be reasonably satisfied that that on the balance of probabilities the death is caused by eligible defence service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as causing death related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a connection to service to be probable. These factors are the only ways I can relate death from a condition to defence service.

I cannot accept death as being related to defence service unless the evidence meets one of the factors set out in the Statement of Principles for the condition causing death. However, I must be reasonably satisfied that the factor exists before the claim can be accepted. Information about the RMA is contained in the Explanatory Attachment to this letter.

Operational and eligible service

The law states that for the death of {+VeteranForename,M} {+VeteranSurname,M} to be accepted as service related, the cause of death must be related in some way to operational or eligible war service. Different standards of proof apply to these two types of service.

When considering operational service I must accept the claim if there is a reasonable hypothesis connecting the death with this service. When considering eligible service I must be reasonably satisfied that that on the balance of probabilities the death is war caused.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as causing death related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable or for a connection to service to be probable.. These factors are the only ways I can relate death from a condition to service.

I cannot accept death as being related to service unless it meets one of the factors set out in the Statement of Principles for the condition causing death. However, for operational service I must be satisfied beyond reasonable doubt that a factor does not exist before the claim can be rejected. For eligible service I must be reasonably satisfied that the factor exists before the claim can be accepted. Information about the RMA is contained in the Explanatory Attachment to this letter.

Eligible and defence service

The law states that for the death of {+VeteranForename,M} {+VeteranSurname,M} to be accepted as service related, the cause of death must be related in some way to eligible war or defence service.

When considering the evidence I must be reasonably satisfied that that on the balance of probabilities the death is caused by eligible war or defence service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as causing death related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a connection to service to be probable. These factors are the only ways I can relate death from a condition to service.

Operational and defence service

The law states that for the death of {+VeteranForename,M} {+VeteranSurname,M} to be accepted as service related, the cause of death must be related to in some way to operational service or eligible defence service. Different standards of proof apply to these two types of service.

When considering operational service I must accept the claim if there is a reasonable hypothesis connecting the death with this service. When considering eligible defence service I must be reasonably satisfied that that on the balance of probabilities the death is caused by defence service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as causing death related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable or for a connection to service to be probable.. These factors are the only ways I can relate death from a condition to service.

Operational, eligible and defence service

The law states that for the death of {+VeteranForename,M} {+VeteranSurname,M} to be accepted as service related, the cause of death must be related in some way to operational service or eligible war or defence service. Different standards of proof apply to these types of service.

When considering operational service I must accept the claim if there is a reasonable hypothesis connecting death with this service. When considering the eligible war or defence service I must be reasonably satisfied that that on the balance of probabilities the death is caused by this service.

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as causing death related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable or for a connection to service to be probable.. These factors are the only ways I can relate death from a condition to service.

Reasons for Rejected Conditions

Onset before all VEA service

In this case symptoms or signs of {Rejected Disability} occurred before the start of service covered by the Veteran's Entitlement Act. Therefore {Rejected Disability} cannot have been caused by this service. Only aggravation of {Rejected Disability} by service can be considered.

Onset after all VEA service

{Rejected Disability} can only be aggravated by factors that are due to service if the symptoms or signs of {Rejected Disability} developed before the end of service covered by the Veteran's Entitlement Act. In this case, as {Rejected Disability} developed after service covered by the Veteran's Entitlement Act , aggravation of {Rejected Disability} cannot be considered. Only causation of {Rejected Disability} by service can be considered.

Aggravating factor due to service prior to the onset of the claimed condition

Operational service

There is a history of {aggravating factor} which may have aggravated {Rejected Disability}. However, the claim for {Rejected Disability} can only succeed under aggravation if the clinical onset of {Rejected Disability} occurred before that part of operational service to which the {aggravating factor} is related. This was not so in this case and therefore {Rejected Disability} cannot be accepted because of aggravation by {aggravating factor}.

[NB - include area of side and site of body where appropriate]

Eligible service

There is a history of {aggravating factor} which may have aggravated {Rejected Disability}. However, the claim for {Rejected Disability} can only succeed under aggravation if the clinical onset of {Rejected Disability} occurred before that part of eligible service to which the {aggravating factor} is related. This was not so in this case and therefore {Rejected Disability} cannot be accepted because of aggravation by {aggravating factor}.

[NB - include area of side and site of body where appropriate]

Final Paragraphs

Operational Service Only

The circumstances of this case do not satisfy the Statement of Principles issued by the RMA in respect of {Rejected Disability}. As a result I find that all the evidence does not raise a reasonable hypothesis connecting {Rejected Disability} and operational service. I am therefore unable to accept it as war caused.

Eligible Service Only

As the circumstances of this case do not satisfy the Statement of Principles issued by the RMA in respect of {Rejected Disability}. As a result I find that all the evidence does not show any reasonable connection between {Rejected Disability} and eligible service. I am reasonably satisfied it was not caused by eligible service.

Operational and Eligible Service

APPENDIX 7

EXTRA SECTIONS FOR EXPLANATORY ATTACHMENT TO REASONS INVOLVING REJECTION OF CONDITIONS WITH RMA SOPS

Each condition has 3 versions - operational service, eligible service and combined.

GOUT

Factors that can cause or aggravate gout:

Active systemic leukemia, myeloid metaplasia, polycythemia vera, multiple myeloma or lead nephropathy.

Treatment with thiazide diuretics, aspirin, nicotinic acid, pyrazinamide or ethambutol.

Factors that can aggravate gout:

The inability to obtain appropriate clinical management for gout.

GOUT

The RMA has issued a statement of principles that states what factors must exist before it can be said that, on the balance of probabilities a connection between eligible service and gout exists. The factors which must be due to that service are outlined below:

Factors that can cause or aggravate gout:

Active systemic leukemia, myeloid metaplasia, polycythemia vera, multiple myeloma or lead nephropathy.

Treatment with thiazide diuretics, aspirin, nicotinic acid, pyrazinamide or ethambutol.

Factors that can aggravate gout:

The inability to obtain appropriate clinical management for gout.

GOUT

The RMA has issued a Statement of Principles which states what factors must exist connecting gout to both operational and eligible service. The factors which must be due to either operational service or eligible service are outlined below:

Factors which can cause or aggravate gout:

Active systemic leukemia, myeloid metaplasia, polycythemia vera, multiple myeloma or lead nephropathy.

Treatment with thiazide diuretics, aspirin, nicotinic acid, pyrazinamide or ethambutol.

Factors which can aggravate gout.

The inability to obtain appropriate clinical management for gout.

MALIGNANT NEOPLASM OF THE LUNG

Factors that can cause malignant neoplasm of the lung.

Smoking specified levels of cigarettes, cigars and pipe tobacco or passive smoking.

Occupational exposure to respirable asbestos fibres, mustard gas, insecticides or herbicides.

working with coke ovens, occupational care of birds, exposure to atomic radiation in Japan, a course of therapeutic radiation, asthma, chronic bronchitis, emphysema, pneumonia or pulmonary tuberculosis.

Factors that can aggravate malignant neoplasm of the lung.

The inability to obtain appropriate clinical management for malignant neoplasm of the lung.

MALIGNANT NEOPLASM OF THE LUNG

The RMA has issued a statement of principles that states what factors must exist before it can be said that, on the balance of probabilities a connection between eligible service and malignant neoplasm of the lung exists. The factors which must be due to that service are outlined below:

Factors that can cause malignant neoplasm of the lung:

Smoking specified levels of cigarettes, cigars and pipe tobacco or passive smoking.

Occupational exposure to respirable asbestos fibres, mustard gas, insecticides or herbicides.

Factors that can aggravate malignant neoplasm of the lung:

The inability to obtain appropriate clinical management for malignant neoplasm of the lung.

MALIGNANT NEOPLASM OF THE LUNG

The RMA has issued a Statement of Principles which states what factors must exist connecting malignant neoplasm of the lung to both operational and eligible service. The factors which must be due to either operational service or eligible service are outlined below:

Factors which can cause malignant neoplasm of the lung (both types of service).

Smoking specified levels of cigarettes, cigars and pipe tobacco or passive smoking.

Occupational exposure to respirable asbestos fibres, mustard gas, insecticides or herbicides.

Factors linked only to operational service which can cause malignant neoplasm of the lung.

Factors which can aggravate malignant neoplasm of the lung.

Inability to obtain appropriate clinical management for malignant neoplasm of the lung

INGROWN TOENAIL

The RMA has issued a Statement of Principles that states what factors must exist to establish a reasonable hypothesis connecting ingrown toenail and operational service. These factors, which must be due to operational service, are outlined below:

Factors that can cause ingrown toenail.

Poor footcare, poor foot hygiene, ill fitting footwear and deformity of the toe or toenail.

Factors that can aggravate ingrown toenail.

Poor footcare, poor foot hygiene, ill fitting footwear deformity of the toe or toenail and the inability to obtain appropriate clinical management for ingrown toenail.

INGROWN TOENAIL

The RMA has issued a statement of principles that states what factors must exist before it can be said that, on the balance of probabilities a connection between eligible service and ingrown toenail exists. The factors which must be due to that service are outlined below:

Factors that can cause ingrown toenail:

Poor footcare, poor foot hygiene, ill fitting footwear and deformity of the toe or toenail.

Factors that can aggravate ingrown toenail:

Poor footcare, poor foot hygiene, ill fitting footwear deformity of the toe or toenail and the inability to obtain appropriate clinical management for ingrown toenail.

INGROWN TOENAIL

The RMA has issued a Statement of Principles which states what factors must exist connecting ingrown toenail to both operational and eligible service. The factors which must be due to either operational service or eligible service are outlined below:

Factors which can cause ingrown toenail:

Poor footcare, poor foot hygiene, ill fitting footwear and deformity of the toe or toenail.

Factors which can aggravate ingrown toenail:

Poor footcare, poor foot hygiene, ill fitting footwear deformity of the toe or toenail and the inability to obtain appropriate clinical management for ingrown toenail.

PEPTIC ULCER DISEASE

The RMA has issued a Statement of Principles that states what factors must exist to establish a reasonable hypothesis connecting peptic ulcer disease and operational service. These factors, which must be due to operational service, are outlined below:

Factors that can cause peptic ulcer disease:

Having been a prisoner of war. Cigarette smoking, experiencing stressful circumstances, being infected with Helicobacter pylori prior to peptic ulcer disease.

Treatment with non steroidal anti inflammatory drugs not more than 14 days before onset of peptic ulcer disease.

Factors that can aggravate peptic ulcer disease:

Cigarette smoking, experiencing stressful circumstances, treatment with non steroidal anti inflammatory drugs and the inability to obtain appropriate clinical management for peptic ulcer disease.

PEPTIC ULCER DISEASE

The RMA has issued a statement of principles that states what factors must exist before it can be said that, on the balance of probabilities a connection between eligible service and peptic ulcer disease exists. The factors which must be due to that service are outlined below:

Factors that can cause peptic ulcer disease:

Cigarette smoking, experiencing severely stressful circumstances, being infected with Helicobacter pylori prior to peptic ulcer disease.

Treatment with non steroidal anti inflammatory drugs not more than 7 days before onset of peptic ulcer disease.

Factors that can aggravate peptic ulcer disease:

Cigarette smoking, experiencing severely stressful circumstances, treatment with non steroidal anti inflammatory drugs and the inability to obtain appropriate clinical management for peptic ulcer disease.

PEPTIC ULCER DISEASE

The RMA has issued a Statement of Principles which states what factors must exist connecting peptic ulcer disease to both operational and eligible service. The factors which must be due to either operational service or eligible service are outlined below:

Factors which can cause peptic ulcer disease:

Cigarette smoking, experiencing stressful or very stressful circumstances, being infected with Helicobacter pylori prior to peptic ulcer disease.

Treatment with non steroidal anti inflammatory drugs before onset of peptic ulcer disease.

Factors linked only to operational service which can cause peptic ulcer disease:

Having been a prisoner of war.

Factors which can aggravate peptic ulcer disease:

Cigarette smoking, experiencing stressful circumstances, treatment with non steroidal anti inflammatory drugs and the inability to obtain appropriate clinical management for peptic ulcer disease.

PSYCHOACTIVE SUBSTANCE ABUSE OR DEPENDENCE

The RMA has issued a Statement of Principles that states what factors must exist to establish a reasonable hypothesis connecting psychoactive substance abuse and operational service. These factors, which must be due to operational service, are outlined below:

Factors that can cause psychoactive substance abuse or dependence:

Experiencing a stressful event and/or having a psychiatric condition prior to onset of the substance abuse or dependence

Factors that can aggravate psychoactive substance abuse or dependence:

As above and/or inability to obtain appropriate clinical management for the substance abuse or dependence.

PSYCHOACTIVE SUBSTANCE ABUSE OR DEPENDENCE

The RMA has issued a statement of principles that states what factors must exist before it can be said that, on the balance of probabilities a connection between eligible service and psychoactive substance abuse exists. The factors which must be due to that service are outlined below:

Factors that can cause psychoactive substance abuse or dependence:

Experiencing a severely stressful event and/or having a psychiatric condition prior to onset of the substance abuse or dependence

Factors that can aggravate psychoactive substance abuse or dependence:

As above and/or inability to obtain appropriate clinical management for the substance abuse or dependence.

PSYCHOACTIVE SUBSTANCE ABUSE OR DEPENDENCE

The RMA has issued a Statement of Principles which states what factors must exist connecting psychoactive substance abuse or dependence to both operational and eligible service. The factors which must be due to either operational service or eligible service are outlined below:

Factors that can cause psychoactive substance abuse or dependence:

Experiencing a stressful or severely stressful event and/or having a psychiatric condition prior to the onset of the substance abuse or dependence.

Factors that can aggravate psychoactive substance abuse or dependence:

As above and/or the inability to obtain appropriate clinical management for the substance abuse or dependence.

FRACTURE

The RMA has issued a Statement of Principles that states what factors must exist to establish a reasonable hypothesis connecting fracture and operational service. These factors, which must be due to operational service, are outlined below:

Factors that can cause fracture:

Trauma, repetitive physical stress, Paget's disease, osteoporosis or osteomalacia, infection, cancer or tumour of the bone.

Factors that can aggravate fracture:

Trauma, Paget's disease, osteoporosis or osteomalacia, infection, cancer or tumour of the bone and/or inability to obtain appropriate clinical management of the fracture..

FRACTURE

The RMA has issued a statement of principles that states what factors must exist before it can be said that, on the balance of probabilities a connection between eligible service and fracture exists. The factors which must be due to that service are outlined below:

Factors that can cause fracture:

Trauma, repetitive physical stress, Paget's disease, osteoporosis or osteomalacia, infection, cancer or tumour of the bone.

Factors that can aggravate fracture:

Trauma, Paget's disease, osteoporosis or osteomalacia, infection, cancer or tumour of the bone and/or inability to obtain appropriate clinical management of the fracture..

FRACTURE

The RMA has issued a Statement of Principles which states what factors must exist connecting fracture to both operational and eligible service. The factors which must be due to either operational service or eligible service are outlined below:

Factors that can cause fracture:

Trauma, repetitive physical stress, Paget's disease, osteoporosis or osteomalacia, infection, cancer or tumour of the bone.

Factors that can aggravate fracture:

Trauma, Paget's disease, osteoporosis or osteomalacia, infection, cancer or tumour of the bone and/or inability to obtain appropriate clinical management of the fracture..

DEPRESSIVE DISORDER

The RMA has issued a Statement of Principles that states what factors must exist to establish a reasonable hypothesis connecting depressive disorder and operational service. These factors, which must be due to operational service, are outlined below:

Factors that can cause depressive disorder:

Have been a prisoner of war. Have experienced a stressor, had a psychiatric condition or had a major illness or injury not more than two years prior to the depressive disorder.

Factors that can aggravate depressive disorder:

Experience of a stressor, having had a psychiatric condition or had a major illness or injury not more than two years prior to the depressive disorder and/or the inability to obtain appropriate clinical management for the depressive disorder.

DEPRESSIVE DISORDER

The RMA has issued a statement of principles that states what factors must exist before it can be said that, on the balance of probabilities a connection between eligible service and depressive disorder exists. The factors which must be due to that service are outlined below:

Factors that can cause depressive disorder:

Experience of a stressor, having had a major illness or injury, having a psychiatric condition not more than one year prior to the depressive disorder.

Factors that can aggravate depressive disorder:

Experience of a stressor, having had a major illness or injury, having a psychiatric condition not more than one year prior to the depressive disorder and/or the inability to obtain appropriate clinical management for depressive disorder.

DEPRESSIVE DISORDER

The RMA has issued a Statement of Principles which states what factors must exist connecting depressive disorder to both operational and eligible service. The factors which must be due to either operational service or eligible service are outlined below:

Factors which can cause depressive disorder:

Experience of a stressor, having had a major illness or injury, having a psychiatric condition prior to the depressive disorder.

Factors linked only to operational service which can cause depressive disorder:

Having been a prisoner of war.

Factors which can aggravate depressive disorder:

Experience of a stressor, having had a major illness or injury, having a psychiatric condition prior to the depressive disorder and/or the inability to obtain appropriate clinical management for depressive disorder.