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ptsd Establishing Service Connection
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Question
mrkman12
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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