Disability Compensation Texas Veterans Commission Fall Conference 2009
Dec 30, 2015
Disability Compensation
Texas Veterans Commission
Fall Conference 2009
Overview
• Comp. = Key
• 6 Lessons
1. Eligibility Criteria
2. Application Procedures
3. Claims Processing Flow
4. Ratings
5. Dependency Requirements
6. Payments
Eligibility Criteria
• Disability– Injured in service
– Aggravation of an injury in service
– Ill in service & continuing problems
– Condition developed in service
– Presumptive condition within 1 year of discharge
– Presumptive condition from exposure
Eligibility Criteria (Cont.)
• Types of Conditions
– Acute Condition
– Chronic condition
– Acute & Chronic
Eligibility Criteria (Cont.)
• Service Requirements– Active Duty
– Disease or Injury during full-time duty in Reserves or National Guard
– Injury during inactive duty for training in Reserves or National Guard
– No Dishonorable discharge
– Not incurred as a result of willful misconduct
Eligibility Criteria (Cont.)
• Service Requirements (Cont.)
– No Length of service requirement
– No wartime service requirement
Eligibility Criteria (Cont.)
• Establishing Service Connection
– Direct Incurrence
– Aggravation
– Presumption
– As a secondary condition
– Provisions of 38 U.S.C. 1151
Application Procedures
• VA Form 21-526
(Review Blank Form Provided)– Application for Compensation and/or Pension– 7 Pages of General Instructions– 4 Parts (A, B, C, & D)– Each part has sections numbered I, II, III, IV etc.– Each page has the Part & Page number at lower
right hand side of the page.
Application Procedures (Cont.)
Documents sent with Application
• Discharge papers
– DD-214 (copy 4)
– Veterans service before 1947
• Army veterans WDAGO 53-98
• Navy personnel NAVPERS Form 553
– Ltr from National archives
Application Procedures (Cont.)
Required Info on Separation Document
1. Branch of Service
2. Dates of Service
3. Character of Separation
Application Procedures (Cont.)
Documents sent with Application (Cont.)
• VA Form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative
– Specific Power of Attorney
– National Organizations 38 (Membership does not mean POA)
– State Organization is TVC
Application Procedures (Cont.)
Documents sent with Application (Cont.)
• VA Form 21-4142, Authorization and Consent to Release Information to the Dept. of VA– Authorizes VA to obtain private medical
records– One per doctor, hospital or clinic– Not required for VA facilities
CLAIMS PROCESSING
Claims Processing Improvement (CPI) Teams (6)
1. Triage Team
2. Pre-Determination Team
3. Rating Team
4. Post-Determination Team
5. Appeals Team
6. Public Contact Team
CLAIMS PROCESSING(Cont.)
1. Triage team
– Receives Mail
– Processes little development claims
– Routes other claims
• Pre-determination
• Appeals
• POW
• Terminal Ill / Over 65
CLAIMS PROCESSING (Cont.)
2. Pre-Determination Team (Pre-D)
– “Develops” claim
• Request SMR’s / STR’s
• Request Service Records
• Request private medical records
• Request Compensation & Pension (C&P) Exam
CLAIMS PROCESSING (Cont.)
3. Rating Team– Renders decisions
(Rating reference is CFR 38 Part 4)
CLAIMS PROCESSING (Cont.)
4. Post-Determination Team• Prepares, inputs & sends notification letters
CLAIMS PROCESSING (Cont.)
5. Appeals Team
Appeal
– Long Process!
– Other options
• Reopened Claim
• Not possible Claims
CLAIMS PROCESSING (Cont.)
Appeals (Cont.)• Notice of Disagreement (NOD)
– VA Form 21-4138 (Statement in Support of Claim)
– Include:• “Notice of Disagreement with decision of
DD-MM-YEAR”• List each issue• If available submit evidence• Elect DRO or Traditional Appeal Process
CLAIMS PROCESSING (Cont.)
DRO = Decision Review Officer
• One Person
• Reviews Entire Claim
• Authority to Grant Benefits
• If DRO continues denial, Sends SOC (Statement of Case) & Form 9
• Form 9 starts Traditional Appeal Process
• Almost ALWAYS better to elect DRO
CLAIMS PROCESSING (Cont.)
Traditional Appeal (Form 9)
• Make a choice of a hearing or not
• List Issue(s) Appealing
• Make a Statement of Argument
CLAIMS PROCESSING (Cont.)
Appeal’s Time Limits
• NOD (Notice of Disagreement)
– 1 Year from date of Decision Letter
• VA Form 9
– 60 Days from Date of SOC (Statement of Case)
– 1 Year from date of Decision Letter
Whichever is Later
CLAIMS PROCESSING (Cont.)
6. Public Contact Team
– Walk-In Inquiries
– Mail Inquiries
– Congressional Correspondences
– Outreach
– Fiduciary Issues
RATINGS
Facts
• Congress Establishes Amounts
• Percentages Increase with Severity of Disability
• May be Rated at 0%
• Percentage is Impairment in Earning Capacity
• May have several ratings but only one combined rating
RATINGS
Combined Ratings (or VA Math)
30% + 20% is 40%
NOT 50%
Explanation:
A Single rating is what it is.
The second and following rating are the percentage of what is left over after the first or previous ratings.
RATINGS
Combined Ratings (Cont.)
30% + 20% = 40%
100% - 30% (Largest Rating) = 70%
20% (Next largest Rating) of 70% (What was left over) = 14%
Therefore 30% + 14% = 44% That Rounds to 40%
RATINGS
Combined Ratings Table
RATINGS
Read table in Matrix format
1st (Largest Number)
on left,
2nd Next largest Number
on Top
RATINGS
Intersecting Number is Rating
Ends in 4 or below
Round Down
Ends in 5 or Above
Round Up
Therefore 30% + 20% = 40%
RATINGS
Combined Ratings Table Practical Application
1. 60% + 10% =
60%
2. 50% + 30% + 20% =
70%
3. 80% + 40% + 30% =
90%
RATINGS
SMC (Special Monthly Compensation)
• Special Allowance for Sever Disabilities
• Usually Loss or Loss of Use of a body part
• Also for Housebound or in need of A&A (Aid and Attendance)
• 8 Designators (K, L, M, N, O, Q, R, & S)
• Combination & Intermediate Ratings make 60 Different Levels
RATINGS
I/U (Individual Unemployability)
• Rated at Less than 100%, but paid at 100% Rate
• SC (Service Connected) disabilities preclude GAINFUL employment
RATINGS
Gainful EmploymentIS = Over the Poverty Threshold for one Person
www.census.gov/hhes/www/poverty/threshld/thresh07
IS NOT = – Odd Jobs– Jobs in a “Protected” Environment
• Family Business• Sheltered Workshop
RATINGS
Temporary Ratings (38 CFR 4.28, 4.29, 4.30)
• Paragraph 28 (Prestabilization)
Normally for recently separated veterans with unstable disability
– Temp. 50% or 100%
• Paragraph 29 (Hospitalization)
Hospitalized more than 21 Days for SC disability
– Temp. 100%
RATINGS
• Paragraph 30 (Surgical/Convalescent)
– Surgery for SC disability requiring min. 1 month convalescence.
– Surgery for SC disability with severe postoperative residuals.
– Immobilization by cast of SC disability of at least 1 major joint.
RATINGS
Permanently & Totally Disabled (P&T)
• Permanent = Reasonably certain to continue throughout lifetime
• Totally = impairment render it impossible to follow gainful occupation
RATINGS
Reviews & Future Exams
• VA will schedule a periodic reevaluation of disabilities likely to improve
RATINGS
Reviews & Future Exams (Cont.)• Reexamination are NOT usually scheduled
if:– Veteran is over 55– Disability is static– Disability fm disease is permanent– Combined rating would not change if
lowered to lowest level possible– Over 5 years without material
improvement
RATINGS
Protected Ratings
• SC rating 10 years or more cannot be revoked
• SC rating 20 years or more cannot be reduced
RATINGS
Incompetency Rating
• Unable to manage own financial affairs
• Considered in every rating with a diagnosis of psychosis
• If incompetency is found, VA will appoint a Fiduciary
RATINGS
Special Issues, Concern to VA & Congress (7)
1. Post-Traumatic Disorder (PTSD)
2. Agent Orange Exposure
3. Prisoner of War (POW)
4. Radiation Exposure
5. AIDS
6. Asbestos Exposure
7. Mustard Gas Exposure
RATINGS
Review 3 Most Common Special Issues
1. Post-Traumatic Disorder (PTSD)
2. Agent Orange
3. Radiation
RATINGS
PTSD
• Three Requirements for SC
1. In-Service Stressor
2. Current Medical Diagnosis
3. Relationship (Nexus) between Stressor & Diagnosis
RATINGS
Stressor
• Threat to one’s life
• Threat to one’s Relatives or Friends
• Seeing another seriously injured or killed
RATINGSIn-Service Stressor• Combat-Related Decoration is stressor
– Any decoration with combat “V”– 12 additional awards, most common:
• Combat Action Ribbon• Combat Infantryman Badge• Combat Action Badge• Purple Heart
• Veteran without a combat decoration– VA Form 21-781(Statement In Support of
Claim For SC for PTSD)
RATINGS
In-Service Stressor
PTSD From Personal / Sexual Assault• Rape• Domestic Battery• Robbery / Mugging• Stalking
VA Form 21-781 A, (Statement in Support of Claim for SC for PTSD
Secondary to Personal Trauma)
RATINGS
Current Medical Diagnosis• Board-certified psychiatrist• Doctorate-Level Psychologist• Resident / Intern under supervision of
above individuals
Nexus (Connection / Relationship)• Specifically addressed in VA exam
NOTE: Diagnosis & Nexus usually determined by VA C&P Exam
RATINGS
Agent Orange
Eleven Presumptive Conditions
(NOTE: Exposure is not a disability)
1. Non-Hodgkin’s Lymphoma
2. Soft-Tissue Sarcoma
3. Hodgkin’s Disease
4. Respiratory Cancers
5. Multiple Myeloma
RATINGSAgent Orange (Cont.)6. Prostate Cancer7. Type 2 Diabetes8. Chronic Lymphocytic Leukemia
Note: 9 through 11 must diagnosed within one year of last exposure
9. Chloracne10. Porphyria Curanea Tarda (PCT)11. Peripheral Neuropathy
RATINGS
Radiation Exposure
Hiroshima, Nagasaki, Nuclear Testing or Occupational Exposure
Ref: 38 CFR 3.309 (d), & 38 CFR 3.311
Extremely Complex
RATINGS
Gulf War
• Environmental Hazards in Gulf War
• Undiagnosed Illness
• 13 Categories of Signs / Symptoms
• Illness must be Chronic (Excess 6 Months)
38 CFR 3.317
Dependency Requirements
• Rating of 30% or more Receive Additional Compensation for Dependents
• Dependents may Include:– Spouse– Child(ren)– Parents
Dependency Requirements
Dependent Spouse
• Proof of Marriage / Prior Marriage IS NOT required unless conflicting information
• Common Law Marriage IS acceptable in Texas (With Required VA Forms)
• Common Law Divorce DOES NOT exist
Dependency Requirements
Common Law Marriage Forms
Veteran – VA Form 21-4138 Addressing;– Agreement of Relationship at beginning– Time Living Together– Places / Dates of Residence– Any Child(ren) Together– Member of Church / Organization as Husband
& Wife– Business, Legal Document or Real Estate
Together
Dependency Requirements (Cont.)
Common Law Marriage Forms (Cont.)
Spouse
– VA Form 21-4170
Relative / Friend (2)
– VA Form 21-4171
Dependency Requirements (Cont.)
Dependent Child(ren)
• Unmarried, AND
• Under 18, OR
• Between 18 & 23 in Approved Education Institution, OR
• Permanently Incapable of Self-Support Before 18
Dependency Requirements (Cont.)
Dependent Child(ren) Relationship
• Natural / Biological Child
• Legally Adopted
• Stepchild living with veteran or receiving 50% support from veteran
(Some exceptions for stepchildren not living with veteran)
Dependency Requirements (Cont.)
Dependent Parents Relationship– Birth Father– Birth Mother– Father through Adoption– Mother through Adoption– Person who stood in relationship of
parent for 1 year prior to entry into service
Dependency Requirements (Cont.)
Dependent Parents
Requirements
– Conclusive Dependency (Below Income Requirement)
– Reasonable Maintenance
(Above Income Requirement, but doesn’t provide for a reasonable standard of living)
Payments
Effective Date
• Date Entitlement Begins
Date Determined by:
• Within 1 year of Discharge = 1st Day of Month following Discharge
• After 1 year of Discharge = 1st Day of Month after claim was received
Payments (Cont.)
Increases (6 Types)
1. Worsened disability
2. Temp increase for hospital / convalescence
3. Entitlement to SMC
4. Establishment of I/U
5. Cost-of-Living adjustment (COLA)
6. Added Dependents
Payments (Cont.)
Reductions (4 Situations)
1. Improvement in SC Disability
2. Loss of Dependent
3. Incarceration
4. Hospitalization
Payments (Cont.)
Incarceration Reduction
• Over 60 days
– 20% or more reduced to 10% rate
– 10% reduced to ½ of 10% rate
Payments (Cont.)
Apportionment
• Compensation not paid to incarcerated Vet may be paid to Dependents
– Dependent must request the Apportionment
– Dependent must show need
Payments (Cont.)
Rate Protected fm Reduction / Discontinuance
• Rate in effect for 10 or more years cannot be revoked
• Rate in effect for 20 or more years cannot be reduced
Payments (Cont.)
Discontinuances:
1. No longer warrants compensable rating
2. Veteran returns to active duty
3. SC was granted on fraud, error or bad faith
Review
7 Lessons
1.Eligibility Criteria
2.Application Procedures
3.Claims Processing Flow
4.Ratings
5.Dependency Requirements
6.Payments
QUESTIONS