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anxiousinMD

Increase Submitted by VA and/or SMC Housebound Math

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Hello and TYIA for any responses and for reading my long post.

BLUF: I would appreciate some insight or just plain ol speculatin on why the VA raters would submit me for a lumbar strain increase (that I didn’t submit for) while working on my current claim? Also, are secondary conditions disqualified in the 60% calculation for SMC Housebound? I know it says the 60% must be separate from the 100% condition, but how does this work if I’m on IU, with secondary conditions? 

I’m probably overthinking at 4am but why would they submit me for an increase for a condition when I didn’t ask them, and the increase has no bearing on the final rating due to VA math, unless it qualifies me for SMC, or they believe I should be qualified. I’ve never raised the issue of SMC and I’m still learning about it trying to figure out my claim, and I know they are supposed to do due diligence, but that’s not my first hunch since that’s why I’m still in this process.

History: I filed a claim in 2015 for PTSD increase and TDIU, was granted increase in 2016 to 70% PTSD, denied TDIU. Combined, 80% with other SC conditions. BBE/VSO said I was denied increase to 100% even though I had a nexus statement from a psychologist saying total social and occupational impairment, at least as likely as not, etc., but they said because I was still employed (I was on long term disability leave but not yet “terminated” and yes they had the relevant evidence through my employer and insurance), and my VA treating provider’s opinion took precedence who didn’t feel my symptoms quite qualified me for total of course, though he‘s a CRNP versus a psychologist and I don’t think he even knows me. I thought they were supposed to take the rating and credentials that favor the Veteran but never mind me. I also survived and was approved for Social Security and life insurance premium waivers during this period without having to appeal, with the same medical information and evidence, with the same VA SC conditions, even coming from VA docs and providers.

Of course I appealed the rating and TDIU denial (they can decide) in 2016. I also submitted a new claim for secondaries to PTSD, and in my fog, with that claim an increase for PTSD and TDIU, even though I already had those on appeal. I believe I read or was told somewhere (or maybe my brain made it up) that if I submitted new evidence, the raters could look back at the effective date and could EED to the original claim if the evidence shows and close the appeal. Or, they could approve me from the date of the new claim and the appeal could deal with the stuff before that. But what they did was what they are apparently supposed to do (according to Peggy and the VSOs): defer the appeal related claims to the appeal. DOH.

Current Status: Early this month my claim progressed and I was granted an increase to 30% for IBS secondary to my 70% PTSD, and since I had a pre-existing 10% for nerve condition and 20% for lumbar strain, that brought me to 90%. My claim never went to complete and I never got the BBE, ebenefits bounced around from gathering of evidence to pending decision approval within days of my last C&P (I had one for PTSD and one for IBS). I’m not sure why they would give me a C&P for PTSD if they are deferring that part of my claim to appeal as I was told. Maybe they’re just giving me a checkup because my 30 appointments and inpatient stays and shock treatments over the past year weren’t enough medical evidence.

I learned of the increase bc I got a small retro and my ebenefits letters and disabilities changed within days, but the claim stayed open. I found out by calling Peggy and VSO that it’s due to an increase for my lumbar strain that someone in the rating chain put in. I do have plenty of evidence in my medical records that show my back is also crap. I got sent to a C&P for my lumbar strain and now I wait in GOE. The C&P examiner, Peggy, VSOs specifically say I was submitted for an increase for my back, not a review. BTW, in ebenefiits in the disabilities section, the PTSD increase is still open, the TDIU disappeared, the IBS is rated, and the lumbar strain doesn’t appear. Yes, I know ebenefits is unreliable and I should find something else to do, but compulsively logging into ebenefits is an activity quite similar to playing a slot machine for me. Every 1 in 10000000 logins I might get a glimmer of hope, and it keeps me going lol.

I Wonder: What difference does it make if I’m rated 20% or 30% for my lumbar strain? Why would this be raised since my overall rating won’t change from 90% either way? Trust me, I AM NOT COMPLAINING AND I AM GRATEFUL, anything they do (and they have been getting faster and more Vet-friendly it seems) positive for the Veteran that saves future agony and torture is an appreciated blessing. It would help in the future in qualifying for SMC, but I don’t qualify with the math now. Just wondering if they don’t have enough to do over there, because in the future I’d probably have to get another C&P. Also, I would have to have another condition at 30% for that math to work out, and I pray nothing else worsens enough for that to happen.

Does “separate” mean it can’t affect the same body system or it can’t be a secondary condition? Because with secondaries, I could potentially qualify for SMC, and therefore the VA rater would be setting me up for success. Otherwise, it just seems like extra work for them when they could close my case and get their quota numbers and help another Vet...again, not complaining but whoever is on my file seems to be thorough regardless.

I know they could be doing anything over there, and I’m glad they’re working on my claim, but just for s&g I’d appreciate any guesses or suggestions, and any help clarifying the SMC Housebound math thing please.

Thank you all.

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Some Well Seasoned (OLD) Vet's completing their IU Claims, mistakenly listed all there major SCs as causing their IU. I know I did, listing 70 PTSD, 50 SA, and 30 CAD. Looking back, in all actuality, it was the PTSD that really caused the employment problem. On the IU Award, it listed all (3) SCs as causing the IU. I believe that removed the possibility of separating the CAD & SA for the 60% SMC S (1) consideration.

Fast forward to 12/15, when the 50% SA got bumped to 100%, the IU Rating disappeared. 01/03/16 E-Ben update showed 100% SC with SMC S (1). This was done by the Sr Rater doing the Quality Review of my 07/15 SA Increase Denial.

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Here is my 2 cents

I believe they add or combined all disability % as you file for them!

Usually Joe Veteran starts out with lets say a 30% S.C. Rating  rather its combined or a stand alone 30% rating.

Few years goes by and Joe comes down with another condition that he thinks should be Service Connected..he proves his S.C. and is rated another 30%..this brings his combined ratings to 60%  once a Veteran reaches the 60% it gives him  the rating ceritera to meet the IU  if he ever comes down with another Service connected condition and  is not at the 100%   if this condition causes Joe to not be able to work  then being he is at 60%  they can use the extra schedular to make him IU paid at the 100% rate although Joe is not 100%

So if Joe files enough claims and wins and is given a # %  they take all his % and combined them together and if he is up to the 100% and still has additional S.C. Conditions that mount up to 60% or above  then those combined % will meet the criteria for the SMC Special Rating Table or one distink  S.C. Condition at 60%....

the rater is suppose to look at all of Joe's S.C. Conditions and see if he meets the SMC Criteria   this is a Mandatory Rating  and give the veteran his due benefits...but some times the rater don't do this...this is one good reason the veteran should stay on top of his claim/claims

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4 hours ago, Buck52 said:

Here is my 2 cents

I believe they add or combined all disability % as you file for them!

Usually Joe Veteran starts out with lets say a 30% S.C. Rating  rather its combined or a stand alone 30% rating.

Few years goes by and Joe comes down with another condition that he thinks should be Service Connected..he proves his S.C. and is rated another 30%..this brings his combined ratings to 60%  once a Veteran reaches the 60% it gives him  the rating ceritera to meet the IU  if he ever comes down with another Service connected condition and  is not at the 100%   if this condition causes Joe to not be able to work  then being he is at 60%  they can use the extra schedular to make him IU paid at the 100% rate although Joe is not 100%

So if Joe files enough claims and wins and is given a # %  they take all his % and combined them together and if he is up to the 100% and still has additional S.C. Conditions that mount up to 60% or above  then those combined % will meet the criteria for the SMC Special Rating Table or one distink  S.C. Condition at 60%....

the rater is suppose to look at all of Joe's S.C. Conditions and see if he meets the SMC Criteria   this is a Mandatory Rating  and give the veteran his due benefits...but some times the rater don't do this...this is one good reason the veteran should stay on top of his claim/claims

This is EXACTLY what happened to me, I was IU PT 30 mh 50 migraines (which is what gave me the IU) and 10 for tmj and 10 for a finger thing...........I was then awarder 60% for another condition along with a bunch of other stuff and an increase in mh to 70% and they denied my SMC S and L even when my neuro and pcp filled out the paperwork stating I needed aid and attendance, rest assured I am fighitng that BS.

 

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Usually to meet the requirements for SMC it depends on the severity of the disability...so if you can't work because of one of your S.C. Conditions and you have IU and another rating 60% or combined ratings 60%or more  then yes you should meet the criteria for the SMC In fact H.B. S

you can't leave home for work  so your consider house bound. they also use LOU (Loss of Use)

Here is the  Criteria for the SMC According to

38 CFR 3.350

you should be able to get the SMC rating and the EED for it.

Edited by Buck52

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