Disability Compensation
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Transcript of Disability Compensation
![Page 1: Disability Compensation](https://reader036.fdocuments.net/reader036/viewer/2022062314/56812c4e550346895d90d70a/html5/thumbnails/1.jpg)
Disability Compensation
Texas Veterans Commission
Fall Conference 2009
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Overview
• Comp. = Key
• 6 Lessons
1. Eligibility Criteria
2. Application Procedures
3. Claims Processing Flow
4. Ratings
5. Dependency Requirements
6. Payments
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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
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Eligibility Criteria (Cont.)
• Types of Conditions
– Acute Condition
– Chronic condition
– Acute & Chronic
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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
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Eligibility Criteria (Cont.)
• Service Requirements (Cont.)
– No Length of service requirement
– No wartime service requirement
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Eligibility Criteria (Cont.)
• Establishing Service Connection
– Direct Incurrence
– Aggravation
– Presumption
– As a secondary condition
– Provisions of 38 U.S.C. 1151
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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.
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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
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Application Procedures (Cont.)
Required Info on Separation Document
1. Branch of Service
2. Dates of Service
3. Character of Separation
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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
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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
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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
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CLAIMS PROCESSING(Cont.)
1. Triage team
– Receives Mail
– Processes little development claims
– Routes other claims
• Pre-determination
• Appeals
• POW
• Terminal Ill / Over 65
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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
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CLAIMS PROCESSING (Cont.)
3. Rating Team– Renders decisions
(Rating reference is CFR 38 Part 4)
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CLAIMS PROCESSING (Cont.)
4. Post-Determination Team• Prepares, inputs & sends notification letters
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CLAIMS PROCESSING (Cont.)
5. Appeals Team
Appeal
– Long Process!
– Other options
• Reopened Claim
• Not possible Claims
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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
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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
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CLAIMS PROCESSING (Cont.)
Traditional Appeal (Form 9)
• Make a choice of a hearing or not
• List Issue(s) Appealing
• Make a Statement of Argument
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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
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CLAIMS PROCESSING (Cont.)
6. Public Contact Team
– Walk-In Inquiries
– Mail Inquiries
– Congressional Correspondences
– Outreach
– Fiduciary Issues
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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
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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.
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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%
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RATINGS
Combined Ratings Table
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RATINGS
Read table in Matrix format
1st (Largest Number)
on left,
2nd Next largest Number
on Top
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RATINGS
Intersecting Number is Rating
Ends in 4 or below
Round Down
Ends in 5 or Above
Round Up
Therefore 30% + 20% = 40%
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RATINGS
Combined Ratings Table Practical Application
1. 60% + 10% =
60%
2. 50% + 30% + 20% =
70%
3. 80% + 40% + 30% =
90%
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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
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RATINGS
I/U (Individual Unemployability)
• Rated at Less than 100%, but paid at 100% Rate
• SC (Service Connected) disabilities preclude GAINFUL employment
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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
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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%
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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.
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RATINGS
Permanently & Totally Disabled (P&T)
• Permanent = Reasonably certain to continue throughout lifetime
• Totally = impairment render it impossible to follow gainful occupation
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RATINGS
Reviews & Future Exams
• VA will schedule a periodic reevaluation of disabilities likely to improve
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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
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RATINGS
Protected Ratings
• SC rating 10 years or more cannot be revoked
• SC rating 20 years or more cannot be reduced
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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
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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
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RATINGS
Review 3 Most Common Special Issues
1. Post-Traumatic Disorder (PTSD)
2. Agent Orange
3. Radiation
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RATINGS
PTSD
• Three Requirements for SC
1. In-Service Stressor
2. Current Medical Diagnosis
3. Relationship (Nexus) between Stressor & Diagnosis
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RATINGS
Stressor
• Threat to one’s life
• Threat to one’s Relatives or Friends
• Seeing another seriously injured or killed
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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)
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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)
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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
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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
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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
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RATINGS
Radiation Exposure
Hiroshima, Nagasaki, Nuclear Testing or Occupational Exposure
Ref: 38 CFR 3.309 (d), & 38 CFR 3.311
Extremely Complex
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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
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Dependency Requirements
• Rating of 30% or more Receive Additional Compensation for Dependents
• Dependents may Include:– Spouse– Child(ren)– Parents
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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
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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
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Dependency Requirements (Cont.)
Common Law Marriage Forms (Cont.)
Spouse
– VA Form 21-4170
Relative / Friend (2)
– VA Form 21-4171
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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
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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)
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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
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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)
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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
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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
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Payments (Cont.)
Reductions (4 Situations)
1. Improvement in SC Disability
2. Loss of Dependent
3. Incarceration
4. Hospitalization
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Payments (Cont.)
Incarceration Reduction
• Over 60 days
– 20% or more reduced to 10% rate
– 10% reduced to ½ of 10% rate
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Payments (Cont.)
Apportionment
• Compensation not paid to incarcerated Vet may be paid to Dependents
– Dependent must request the Apportionment
– Dependent must show need
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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
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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
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Review
7 Lessons
1.Eligibility Criteria
2.Application Procedures
3.Claims Processing Flow
4.Ratings
5.Dependency Requirements
6.Payments
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QUESTIONS