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  • 14 Questions about VA Disability Compensation Benefits Claims

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    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
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  • Can a 100 percent Disabled Veteran Work and Earn an Income?

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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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mrkman12

Establishing Service Connection

Question

Establishing Service Connection For Veterans Affairs Disability Compensation

Before November 2000, when the VCAA was enacted,

veterans had to obtain a medical diagnosis of a current disability on

their own. The VA was not generally obligated to help them in obtaining

this medical evidence. Some veterans, who could not afford a private

doctor, were placed in a no win situation. They could not receive

disability compensation until they submitted a medical diagnosis of their

current disability; they could not get the VA to provide them with a free

medical examination to obtain this diagnosis because veterans who already

had service-connected disabilities were more likely to receive free VA

medical care; and they could not obtain a medical diagnosis from a private

doctor because they could not afford to pay for the private doctor. As

a result of the VCAA, most veterans who file an original claim for

disability compensation do not need to obtain a medical diagnosis on their

own. The VA is generally obligated to provide veterans with a VA medical

examination to diagnose the current medical condition. There are only a

few legitimate reasons for which VA may refuse to schedule a VA medical

examination." Veterans Benefits Manual 2007 and a medical

nexus connecting 1 and 2. An in-service injury/disease

means that for the most part it must be documented in the veteran’s

service medical records (SMR’s). One thing to keep in mind is that,

generally, the in-service injury/disease must be shown to be “chronic”

while in-service. If it is not shown to be a “chronic” condition while

in-service, then you’ll more than likely need an Independent Medical

Opinion (IMO) to substantiate the claim. If a veteran doesn’t have either

a documented “chronic” condition, or an IMO, the VA will more than likely

state that the claimed condition is “Acute and Transitory,” meaning that

the injury/disease resolved itself and there is no residuals. A

current condition with a medical diagnosis means that the claimed

condition has to show current residuals from that in-service-injury, and

it must have a current diagnosis from a physician.. A lot of times the

diagnosis can and will be obtained from the VA C&P exam. If the VA

sees that your condition was “chronic” while in the service, or that you

have medical documentation of continuity of treatment since discharge,

more often than not they will schedule the veteran for a C&P exam to

obtain the needed diagnosis and current disabling affects of the claimed

disability. Something connecting the two means either continuity of

treatment of the claimed disability from time of discharge to the present,

or, if this is not the case, then an IMO will be needed from a physician.

A lot of times an IMO is a critical part of the veterans claim. An IMO can

sway the benefit of the doubt in the veteran’s favor if the claim is

borderline, or it can flat out prove service-connection when one of the

three components of establishing service-connection aren’t met! For

example, by borderline I mean let’s say that a veteran was seen for lower

back pain once while on active duty over a period of a five year

enlistment. And now it is ten years since his discharge and the veteran

hasn’t been seen for the lower back until recently, or only had one

episode of back pain within those ten years since getting out of the

military. The veteran will need an IMO stating something to the affect

that his current lower back condition is some how related to the episode

while on active duty. If the RVSR (Rating Veteran Service Representative,

or “Rating Specialist”) is very liberal in applying the regulation, he/she

may award service-connection without the IMO. However, if the RVSR is “by

the book,” then he/she may deny service-connection in the absence of a

good IMO. An example of where an IMO can establish service-connection

with which one or more of the three criteria listed above are absent would be,

let’s say that a veteran was seen one time for a knee condition while on

active duty and this incident is noted in his SMR’s. Ten years later the

veteran is experiencing pain in that same knee but didn’t have any type of

treatment since his discharge, he would need a really good IMO to

establish that his current disability is somehow related to the in-service

episode. As far as presumptive service-connection is

concerned, a veteran needs to be able to show that a condition listed in

§3.307, §3.308, and §3.309 has manifested itself within the prescribed

time limits after separation from the service. A presumptive condition

does not need to be noted in a veteran’s SMR’s, hence presumptive, or it’s

presumed that the said disability/disease occurred while in the service.

There are some presumptive disabilities that do need to have manifested

themselves within the first year after separation and to degree of 10%

disabling in order to warrant presumptive service-connection. One common

one is Arthritis. Filing the claim: Once you have

determined that you have met three basic criteria of disability

compensation, you should then file the claim with your local Regional

Office. There are two types of claims for initial service-connection; an

Informal claim and a Formal claim. An Informal claim is some type of

communication to your local regional office in which you state you intend

to apply for disability compensation. This communication can be a written

letter, or fax, a telephone call or even an email. The best way, however,

is something in writing. When a claimant makes an informal claim with VA,

they need to clearly identify the disability for which they intend to

apply for, give the VA your SSN and dates and branch of service, and make

sure you send it via certified mail with return receipt! After you have

sent your informal claim to VA, you have up to one year to send the VA

your Formal Claim. In this one year period, I would recommend that you get

together all of your medical records and so forth that will support your

claim. If you send the VA your formal claim within the one year time

period of the informal claim and VA grants your claim, the effective date,

or the day you start to receive disability compensation, is the date of

your informal claim. This could mean a lot of money in

retro! A Formal Claim for disability compensation is the VA

Form 21-526. You should fill this out to the best of your ability. You

should attach any Service Medical Records, Private Treatment records

relevant to your claimed disability(ies), certified copy of your DD 214,

copies of marriage certificates divorce decrees and dependent birth

certificates. By attaching these documents, you’ll speed up the processing

of your claim quite a bit. However, you do not need to attach those

documents if you do not have them in your possession. If you do not have

any of those medical records, the VA will assist you in obtaining those by

asking you to fill out VA Form 21-4142 for each facility were those

records are located. One important side note; make sure you sign the VA

Form 21-526! Important: You do not need to submit an Informal

claim. You can file VA form 21-526 without informing VA of your intention

to file for disability compensation. What happens after I file

my Formal claim? After you send VA your Formal claim, there are

a number of “teams” at your local regional office that process your

application. There are essentially six "teams" at a Regional office

that make up the "process." When a veteran files a claim for benefits with

VA, it is received at what is called a 'Triage Team.' This is where the

incoming mail is sorted and routed to the different sections or other

"teams" to be worked. Picture this as a Triage unit at a Hospital. There

they decide who goes where according to the injury/condition involved.

This is the way it works at VA too. The main function of the Triage Team

is to screen all incoming mail. Within the Triage Team there are other sub

components; the Mail Control Point, Mail Processing Point, and to a

certain extent supervision of the files activity. The mail control point

is staffed with VSR (Veteran Service Representatives) who are actually

trained in claims processing. This is also where they receive and answer

the IRIS inquiries. The mail processing point is where chapter 29/30

claims (a bit later on theses types of claims) are processed/awarded, and

to a certain extent dependency issues are resolved. The next step

is the "Pre-Determination Team." This is where your claim for benefits is

sent to be developed, meaning verification of service from the Service

Department if a certified copy of the DD 214 is not submitted by the

veteran, SMR's are obtained from St. Louis if they weren’t sent in already

by the veteran, any CURR verifications are done for PTSD stressors, any

private treatment records are obtained under the "Duty to Assist," and

inferred issued are identified. Once the Pre-Determination Team figures

out what you’re claiming, they’ll send you what’s known as a “Duty to

Assist” letter. This letter states what type of claim you are filing, what

conditions you are claiming, and what the regulations say you must show to

have your claim granted. It will also state the evidence needed by VA to

support your claim, and what VA is doing or has done. The letter will also

explain VA's “Duty to Assist” you in obtaining the evidence to support

your claim. There will also be a response form that you should fill out

and return. If you do not return this form or mark the box that you have

additional evidence to submit, the VA must wait 60 days to further process

your claim. As your claim progresses further though the Pre-Determination

Team, you may or may not receive other letters. Examples of those letters

include: follow-up letters to let you know VA requested something from a

third party and there is a delay in their reply, letters requesting that

you provide something to VA to support your claim. The Pre-Determination

Team may also send you a computer generated letter telling you they are

still working on your claim. That letter is pretty interesting because it

means a couple of things have happened with your claim; 1) your claim was

reviewed by someone recently or 2) your claim has aged where the computer

system is telling the regional office that they must look at your claim.

One thing to keep in mind is that every time VA sends you a letter,

regardless if it’s for information you already sent them, you should

always respond with a letter via certified Mail with return receipt. If

you already sent something to VA that they previously requested, just send

them a letter stating that you already submitted the information and when

you sent it. Once all the developmental work has been done on a claim, it

is then designated as "Ready to Rate" and sent to the Rating

Activity. The Rating Activity or “Rating Board” is where most

veterans want to have their claim. This is where the claim for benefits is

decided. The RVSR (Rating Veteran Service Representative, or “Rating

Specialist”) is the person who rates a veteran's claim. They review the

entire C-file to insure it is ready to be rated, and schedule any C&P

exams that may be needed if not already done so by the Pre-Determination

Team. If a C&P exam is needed they go ahead and do the paperwork to

schedule this. Once the RVSR has all the needed paperwork to rate the

claim, they make their decision. If the RVSR determines that there is

something missing from the claim to make a decision, they send the claim

back to the Pre-Determination Team for further development. Once they have

reached their determination, they produce a rating decision with their

decision and forward the C-file to the Post-Determination Team. The

Post-Determination Team is where the rating decision is promulgated. In

other words, it is where the decision gets entered into the system and the

rating decision is prepared and sent out to the veteran. If the veteran

has a Power of Attorney (POA), they give a heads up to them as to what the

decision was. If a claim has been granted and the retro involves over

$25,000.00, it is sent to the VSCM (Veterans Service Center Manager) or

their assistant for a third signature. The Post Determination Team also

does the following action; accrued benefits claims not requiring a rating,

apportionment decisions, competency issues not requiring a rating,

original pension claims not requiring a rating, dependency issues,

burials, death pension, and specially adapted housing and initial CHAMPVA

eligibility determinations when a pertinent rating is already of

record. The Appeals Team handles appeals in which the veteran has

elected the DRO review. They also handle any remands that have been sent

back from the BVA and the Court. The Appeal Team is a self containing unit

within the Regional office. They make determinations on appeal, make

rating decisions that are on appeal, do any developmental work on any

issue that may be on appeal, and issue any SOC's and SSOC's in conjunction

with their review. The Public Contact Team’s primary functions are

to conduct personal interviews with, and answer telephone calls from

veterans and beneficiaries seeking information regarding benefits and

claims. In some regional offices, depending on their workload, also

handles IRIS inquiries and fiduciary issues. As one can see the VA

claims process can be complex. In essence a veteran’s claim is

continuously going from one team to another until it has been decided.

This process can be rather lengthy depending on what regional office has

jurisdiction over your claim and their pending workload. During this

process a veteran may want to find out the status of their claim. This

should be done through the VA’s IRIS website inquiry system. Through this

inquiry system, the veteran will get much more accurate information then

by calling the 1-800 number. The 1-800 will only connect you to the

regional offices “Public Contact team.” These employees aren’t really

trained to deal with the different processing stages and so forth and

aren’t able to give very accurate information in that regard. The

intention of the 1-800 number and the Public Contact team is really to

give general benefits information and send out forms to claimants, not to

try and track a veterans claim. Furthermore, veterans’ claims aren’t like

tracking a UPS package where it travels in a straight line to its end

destination. Veterans’ claims will end up bouncing from team to team at

the regional office until all of the work required to make a decision is

done.

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Thank you for your post but it helps us if you cite a link or source for cut and paste information.

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Thank you for your post but it helps us if you cite a link or source for cut and paste information.

thanks pete,

I read this some where while working on my informal appeal and copied it, was just reading it before signing on and wanted to know it this information is some what accurate, will remember to add the link next time and not waste the members time.... mark

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No you are ok it is not a waste of time and all have to learn. Your explanation is appreciated.

Thank you for your post

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thanks pete,

I read this some where while working on my informal appeal and copied it, was just reading it before signing on and wanted to know it this information is some what accurate, will remember to add the link next time and not waste the members time.... mark

mrkman12,

How do you define "informal appeal" ?

What would be a reason to file an "informal appeal" ?

carlie

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I don't think the concept of "informal appeal" exists. You can file an informal claim, but not an informal appeal. I disagree with the statement that a vet does not need to get their own medical opinion. The C&P exam you get under VCAA is the very minimum you need to try and get service connected or an increase. I would still be at 10% if I depended on C&P exams provided by the VA.

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