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VA Disability Claims: 5 Game-Changing Precedential Decisions You Need to Know
Tbird posted a record in VA Claims and Benefits Information,
These decisions have made a big impact on how VA disability claims are handled, giving veterans more chances to get benefits and clearing up important issues.
Service Connection
Frost v. Shulkin (2017)
This case established that for secondary service connection claims, the primary service-connected disability does not need to be service-connected or diagnosed at the time the secondary condition is incurred 1. This allows veterans to potentially receive secondary service connection for conditions that developed before their primary condition was officially service-connected.
Saunders v. Wilkie (2018)
The Federal Circuit ruled that pain alone, without an accompanying diagnosed condition, can constitute a disability for VA compensation purposes if it results in functional impairment 1. This overturned previous precedent that required an underlying pathology for pain to be considered a disability.
Effective Dates
Martinez v. McDonough (2023)
This case dealt with the denial of an earlier effective date for a total disability rating based on individual unemployability (TDIU) 2. It addressed issues around the validity of appeal withdrawals and the consideration of cognitive impairment in such decisions.
Rating Issues
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Tbird, -
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Are all military medical records on file at the VA?
RichardZ posted a topic in How to's on filing a Claim,
I met with a VSO today at my VA Hospital who was very knowledgeable and very helpful. We decided I should submit a few new claims which we did. He told me that he didn't need copies of my military records that showed my sick call notations related to any of the claims. He said that the VA now has entire military medical record on file and would find the record(s) in their own file. It seemed odd to me as my service dates back to 1981 and spans 34 years through my retirement in 2015. It sure seemed to make more sense for me to give him copies of my military medical record pages that document the injuries as I'd already had them with me. He didn't want my copies. Anyone have any information on this. Much thanks in advance.-
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RichardZ, -
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Caluza Triangle defines what is necessary for service connection
Tbird posted a record in VA Claims and Benefits Information,
Caluza Triangle – Caluza vs Brown defined what is necessary for service connection. See COVA– CALUZA V. BROWN–TOTAL RECALL
This has to be MEDICALLY Documented in your records:
Current Diagnosis. (No diagnosis, no Service Connection.)
In-Service Event or Aggravation.
Nexus (link- cause and effect- connection) or Doctor’s Statement close to: “The Veteran’s (current diagnosis) is at least as likely due to x Event in military service”-
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Tbird, -
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Post in ICD Codes and SCT CODES?WHAT THEY MEAN?
Timothy cawthorn posted an answer to a question,
Do the sct codes help or hurt my disability ratingPicked By
yellowrose, -
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Post in Chevron Deference overruled by Supreme Court
broncovet posted a post in a topic,
VA has gotten away with (mis) interpreting their ambigious, , vague regulations, then enforcing them willy nilly never in Veterans favor.
They justify all this to congress by calling themselves a "pro claimant Veteran friendly organization" who grants the benefit of the doubt to Veterans.
This is not true,
Proof:
About 80-90 percent of Veterans are initially denied by VA, pushing us into a massive backlog of appeals, or worse, sending impoverished Veterans "to the homeless streets" because when they cant work, they can not keep their home. I was one of those Veterans who they denied for a bogus reason: "Its been too long since military service". This is bogus because its not one of the criteria for service connection, but simply made up by VA. And, I was a homeless Vet, albeit a short time, mostly due to the kindness of strangers and friends.
Hadit would not be necessary if, indeed, VA gave Veterans the benefit of the doubt, and processed our claims efficiently and paid us promptly. The VA is broken.
A huge percentage (nearly 100 percent) of Veterans who do get 100 percent, do so only after lengthy appeals. I have answered questions for thousands of Veterans, and can only name ONE person who got their benefits correct on the first Regional Office decision. All of the rest of us pretty much had lengthy frustrating appeals, mostly having to appeal multiple multiple times like I did.
I wish I know how VA gets away with lying to congress about how "VA is a claimant friendly system, where the Veteran is given the benefit of the doubt". Then how come so many Veterans are homeless, and how come 22 Veterans take their life each day? Va likes to blame the Veterans, not their system.Picked By
Lemuel, -
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Question
Berta
From alamostation email (ALLVETS)
Military Update: Task force to recommend Tricare reform
By Tom Philpott, Special to Stars and Stripes
Pacific edition, Saturday, May 26, 2007
The Pentagon-appointed Task Force on the Future of Military Health will endorse higher Tricare fees, deductibles and co-payments for under-65 retirees and their families in an interim report to be sent to Congress on May 31.
It also will back other key features of the Tricare “reform” package first proposed last year by the Department of Defense. These include:
Raising beneficiary co-payments on prescriptions filled in the Tricare retail pharmacy network.
Indexing Tricare fees and deductibles so that automatic annual adjustments keep them in step with rising health-care costs.
Establishing tiers for the new Tricare fee structure, probably based on rank at retirement, so retirees with bigger annuities pay more for their health-care coverage and retirees with smaller annuities pay less.
The task force won’t endorse every aspect of the “Sustain the Benefit” plan floated last year to raise beneficiary cost shares. For example, the task force wants higher fees and deductibles phased in over three to five years rather than over two years, as DOD initially proposed, or the single-year spike in fees unveiled, with a whiff of desperation, in DOD’s 2008 budget.
Also, the task force will propose that higher Tricare fees and deductibles be set so that, when fully phased in, they are no more burdensome for retirees and their families than fee levels set in 1996 when Tricare was launched.
The task force goes further than the DOD’s proposal in one area. It favors periodic adjustments to Tricare’s catastrophic cap, the maximum amount of out-of-pocket expenses beneficiaries face in any given year. The current cap is $1,000 for active-duty families and $3,000 for other Tricare-eligible families. The original DOD plan would have left the caps unchanged.
Co-chaired by economist Gail R. Wilensky and Air Force Vice Chief of Staff Gen. John D.W. Corley, the 14-member task force outlined its interim recommendations May 23 at a public meeting of the Defense Health Board.
The health board is a standing panel of experts who advise the secretary of defense. The task force functions as a subcommittee of the health board. But it was Congress that ordered it established last year to review Tricare costs and fees after lawmakers rejected the DOD proposals.
The task force’s interim recommendations fall into four areas, two of which would directly impact beneficiary cost shares: higher retail drug co-pays and higher Tricare fees. Specific levels of fees, deductibles and co-pays recommended won’t be detailed until a “final report,” Wilensky said. That report is due in December.
The task force, she said, wants pharmacy co-payments raised on prescriptions filled outside of military treatment facilities to encourage use of more cost-effective alternatives, particularly the Tricare mail order option.
The task force wants Tricare fees realigned for under-65 retirees so they are more “fair” to taxpayers yet still recognize retirees’ “years of demanding service” to the nation, she said. Again, the task force won’t unveil specific proposed fee levels until their final report.
Wilensky said Tricare benefits will remain generous compared to all other public or private plans. The higher fees, however, will take into account “very large expansions in benefits” since the mid-1990s while Tricare fees, deductibles and co-pays were left unchanged.
“The portion of the cost borne by beneficiaries should be increased to levels that are below” the Federal Employees Health Benefit Plan (FEHBP) or the most generous private sector plans, Wilensky said. They also should be set at or below inflation-adjusted fee levels beneficiaries paid back 1996.
To soften the blow of higher fees and of indexing them to inflation, Wilensky said Congress could consider a one-time increase in military retirement pay, if deemed appropriate. But Wilensky suggested it is past time to begin to reverse the ever-widening cost differential for health care paid by working-age military retirees versus other American workers.
Besides adjusting pharmacy co-pays and Tricare fees, the task force will endorse: “best practice” acquisition strategies for pharmacy drugs; spot audits of the Defense Enrollment Eligibility Reporting System (DEERS) to ensure enrollees truly are eligible for Tricare; closer screening of retirees and dependents for alternative health insurance which, by law, must reimburse Tricare for care provided to any dual-eligible beneficiaries.
Steve Strobridge, co-chair of The Military Coalition, an umbrella group of service and veterans association, urged the task force during the meeting’s public comment period, not to ignore factors that might have skewed the cost of military health care since 1996. For example, in measuring DOD cost growth compared to fee levels, he said, the task force should consider the downsizing and closing of many base hospitals and the cost today of sending military doctors to war and, therefore, many more beneficiaries to get care more costly care from Tricare civilian providers.
Wilensky said fees won’t be reset based on some percentage of overall military health care costs. But the task force will recognize that fees have been flat for 11 years, she said, and during that time the beneficiary’s cost share has slipped from about 11 percent down to four percent.
Over the same period, added another task force member, retired Army Maj. Gen. Nancy Adams, the value of the health benefit has improved greatly. For retirees, the promise of “space available care” first made in the 1950s has been replaced with “universal access” to care on base or, more often, through a network of civilian physicians. Adams called it a “highest-quality” benefit having few limitations.
Dr. Gregory A. Poland, Defense Health Board president, advised the task force that the board is “very supportive” of its interim recommendations.
To comment, e-mail milupdate@aol.com, write to Military Update, P.O. Box 231111, Centreville, VA, 20120-1111 or visit: www.militaryupdate.com
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GRADUATE ! Nov 2nd 2007 American Military University !
When thousands of Americans faced annihilation in the 1800s Chief
Osceola's response to his people, the Seminoles, was
simply "They(the US Army)have guns, but so do we."
Sameo to us -They (VA) have 38 CFR ,38 USC, and M21-1- but so do we.
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