Transcript Quarterly Training

SOTS Annual Training 2012
Fully Developed
Claims
Thomas Meadows
TDVA Training Officer
615-441-3384 or [email protected]
4
DEVELOPMENT AND
SECONDARY ISSUES
Establishing a disability as service
connected condition
2
ESTABLISHING SERVICE
CONNECTION
 There are five ways of establishing that a disability
is service-connected:


Direct: Service medical records show that the
condition claimed was diagnosed during military
service, and condition continues to affect the individual
economic capacity. (38 CFR 3.304)
Aggravation: By demonstrating that a condition that
existed prior to military service was aggravated
beyond normal course – recently the VA has
determined that a base be established.(38 CFR 3.306)
3



Presumptive Illness: Means the veteran has
contracted a condition/disease during his/her
military service. (38 CFR 3.307 & 3.309)
Secondary: By demonstrating that a condition
is caused or approximately the result of, or
linked to an existing SC.(38 CFR 3.310)
Injury as a result of treatment: Where disease,
injury, death or the aggravation of an existing
disease or injury occurs as a result of having
submitted to examination, medical or surgical
treatment, or hospitalization in the pursuit of
Vocational Rehabilitation. (38 CFR 3.800)
7
MORE ON COMPENSATION
 If a vet gets a disease or injury and it resolves
without residuals, it is considered acute/transitory
and service connection cannot be established. (38
CFR 3.4)
 In the line of duty & Willful misconduct: An injury
or disease acquired as the result of the veterans
own willful misconduct. (38 CFR 3.1(m)(n)
5
WHAT TYPE OF EVIDENCE
WILL YOU NEED BASED ON
THE FOLLOWING
 A vet reports to you while on active duty he hurt
his back, and both knees. He served with the
101st ABN; made many jumps but rarely sought
medical attention or complained.
 What type of evidence will you need to submit to
prove an incurred condition?
6
AGGRAVATED &
PRESUMPTIVE CONDITIONS
 While playing on his units baseball team during
active duty, the veteran re-injured a pre-existing
condition (ankle injury). The ankle today remains
painful and effects locomotion. What type of
evidence will you need to secure? (38 CFR 3.303
& 3.306)
 L. Berman comes to you and indicates that he has
diabetes and he is a Vietnam era veteran. What
evidence is needed to prove Berman’s case? 38
CFR 3.309(e)
7
SECONDARY DISEASE /
CONDITION
 A veteran was treated in the service for a right
knee condition. After discharge he was granted
10% for impairment to his knee. Later on, he was
crossing a street and was forced to run in order to
avoid being hit by a drunk driver. His SC knee
gave out and he fell and injured his other knee.
What do you have to prove in order to SC the other
knee? (38 CFR 3.310)
8
CLAIMS DEVELOPMENT
 The granting of veteran’s benefits is based on
complying with congressional laws and regulations that
are enforced by the VA. The VA must provide
assistance to the veteran in the preparation and
presentation of their claim.
 As a veteran’s service officer(VSO) acting on behalf of
an accredited organization chartered by Congress and
recognized by the VA for claims representation, you
have assumed the responsibility for providing direct
assistance to the veterans, their dependents and
survivors for any VA benefit.
9
CLAIMS DEVELOPMENT (CONT)
 One of the most important responsibilities of a VSO is to
ensure that the claim receives due process under the laws
and regulations of the VA. Once a POA is signed, there exists
a legal obligation to ensure that all claims and evidence are
properly and timely filed.
 The claims process requires specific actions by all parties.
The claimant must ask for benefits and supply
information/evidence and participate at all stages. The VSO is
responsible for informing the claimant what forms and
documents are required to be submitted to VA and submit
claims timely. Also, that VA follows its due process procedure
and Duty to Inform and Duty to Assist.
10
CLAIMS DEVELOPMENT (CONT)
 The DVA is responsible for processing the claim in a
timely manner and informing the claimant and the
VSO of the results of his or her request.
 Remember, you must file a Fully Developed Claim
whenever possible.
11
NON- FEDERAL & FEDERAL
RECORDS
 VA shall make reasonable efforts to assist claimant.
Submit initial request with 60 days to respond and
one follow up with another 30 days to respond.
 VA will continue attempts until VA receives a
response form the custodian of record that the
records do not exist.
12
QUESTION 1
 SMR’s for a KS vet show that he sustained a back
strain during Active Duty in 1951, with one follow up
treatment for low back pain. Vet was discharged in
1954; on separation report condition was noted as
resolved. Private medical evidence dated 1981
indicates lumbosacral strain while lifting boxes at
work. In 2000 a L4-5 discectomy is performed.
Current medical evidence shows postoperative
residuals of discectomy with DDD.
13
QUESTION 2
 A recently discharged vet from the Army comes to see
you. He is complaining of left hip pain. His DD 214
shows Airborne Ranger. He states he had multiple
(jump record shows 20 jumps) parachute jumps. He
claims on 3 jumps he landed awkwardly, injuring his
hip but did not seek medical treatment. He used over
the counter medications for continued pain. He submits
spouses statement which indicates he complained in
service to her and presently stopped doing yard work.
SMR’s are silent. Examine/medical opinion?
14
QUESTION 3
 SMR’s of a Vietnam era veteran show complaint of
gastric distress and gastrointestinal complaints.
Treated with Tagamet. SMR indicated condition
resolved. Post service medical records contain several
entries showing treatment for various gastrointestinal
complaints over the past 20 years; with a current
diagnosis of GERD. The vet wants you to file for SC for
gastro condition. What would you say?
15
PROXIMATE RESULTS,
SECONDARY CONDITIONS
 Under 38 CFR 3.310, disabilities due to or the result of
a service connected disease or injury shall be service
connected. When the condition is SC, the secondary
condition shall be considered a part of the original
condition. In this situation you must investigate the
differences between conditions caused by diseases
and ones caused by injury. Lets look at a couple of
examples.
16
FULLY DEVELOPED CLAIMS
 The Fully Developed Claims (FDC)
Program is the fastest way of getting
your compensation or pension claim
processed.
 Participation in the FDC Program allows
for faster claims processing while
preserving great quality of service and
your right to appeal a decision.
25
 Claim must be a rating related claim for
live compensation



Original
Secondary
Increased service connected claims
 Application form 21-526 EZ to include
Fully Developed Claim Certification
 VA forms available at
www.va.gov/vaforms or on Vetra/Spec
 You must submit all relevant private
medical records for the disabilities you
are claiming.
18
 You must identify any treatment records
from a Federal Facility such as VA Medical
Center, Outpatient Clinic, or Community
Based Outpatient Clinic (CBOC)
 For Guard and Reserve members you must
submit any and all Service, Treatment, and
Personnel Records in the custody of your
Unit(s).
 Medical can be in the form of letters from
Physicians, Hospital records, or Disability
Benefit Questionnaires. (DBQ’S) Located in
Vetra/ Spec or VA site:
http://benefits.va.gov/TRANSFORMATION/disabilityexams/
19
 If claiming dependents, must complete
VA form 21-686c
 The evidence must show injury in
service, or a disease that began in
service or was aggravated by service.
 You must be diagnosed with a current
physical or mental disability related to
service.
 A relationship or NEXUS must be
established between claimed disabilities
and an injury, disease, symptoms, or
event in military service.
20
 PRESUMPTIVES 3.309: Example Agent
orange, POW, and Radiation.
 What if you don’t have all the evidence?


File an informal Claim Letter or a 21-4138;
must clearly identify the disability being
claimed:
“I intend to apply for compensation benefits
for the following disabilities:
__________________________________
under the FDC Program. This statement is
to preserve my effective date for
entitlement to benefits. I am in the process
of assembling my claim package for
submission”.
21
NSC PENSION
 Criteria:






NSC Pension Claims
21-527EZ Original Claims
Fully Developed Claim Certification Form
must be completed.
All necessary income and net worth in
formation must be submitted
All private medical must be submitted.
Need for DBQ(see compensation
instructions)
30
 Names and addresses of Federal
facilities where you receive treatment to
include dates of treatment
 21 2680 If Claiming Aid and Attendance
21 0779 If in a Nursing Home
 Guard and Reserve records
 Dependents 21-686c
 What the evidence must show:


90 Days service; one of Wartime
24 Month Active Duty Requirement 9-8-80
Enlisted 10-16-81 Officers
23
Permanent and Total Disability Single
60% or Combined 70% one disability
being 40% or more.
 Over 65
 Patient in a Nursing Home for long
term care
 Receiving Disability SS or SSI
 Exception 3.321 B
 Your Net Worth and Income must be
within limits.

24
Handouts #1, #2 & #3:
Fully Developed Claims
(Double click to open)
25