Presentation on theme: "SOTS OCTOBER 21-23, 2009 IDENTIFYING AND PREPARING READY-TO-RATE CLAIMS."— Presentation transcript:
SOTS OCTOBER 21-23, 2009 IDENTIFYING AND PREPARING READY-TO-RATE CLAIMS
OVERVIEW Discuss what makes a claim ready-to rate and its path to the rating board. We will identify the different types of claims. Look at what the VAs responsibilities are and what the claimants responsibilities are. And finally, what we can do to develop the different types of claims.
Valid Claim Medical/lay evidence sufficient to support contentions Status Income (if applicable)
Triage Pre-Determination Rating Post Determination
INFORMAL -- 38 CFR 3.155 FORMAL -- 3.151(a) ORIGINAL -- 3.160(b) FINALLY ADJUDICATED CLAIM -- 3.160(d) REOPENED -- 3.160(e) NEW CLAIM FOR INCREASE – 3.160 (f)
TYPES OF CLAIMS Informal Claim – Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by the Department of Veterans Submitted by: - Claimant - His/her duly authorized representative (if POA in effect at that time) - A member of Congress - Some person acting as next friend of a clamaint who is not sui juris
TYPES OF CLAIMS Informal (cont) Receipt of informal claim requires VA to send claimant application form. Formal claim must be received by VA with one year of date application is mailed to claimant
TYPES OF CLAIMS Formal Claim – A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. Original Claim – An initial formal application on a form prescribed by the Secretary.
TYPES OF CLAIMS Finally Adjudicated Claim – An application, formal or informal, which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earlier.
TYPES OF CLAIMS Reopened Claim – Any application for a benefit received after final disallowance of an earlier claim, or Any application based on additional evidence or a request for a personal hearing submitted more than 90 days following notification to the appellant of the certification of an appeal and transfer of applicable records to the BVA.
TYPES OF CLAIMS New Claim – Simply an original claim for a benefit not previously applied for. Claim for Increase – Any application for an increase in rate of a benefit being paid under a current award, or resumption of payments previously discontinued.
REOPENED CLAIM New and material evidence is required to reopen a claim. (38 CFR 3.156) What is new and material evidence?
New evidence means existing evidence not previously submitted to VA decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.
The Veterans Claims Assistance Act (VCAA) of 2000, PL 106-475, requires substantially complete applications for VA benefits. All development must be completed before deciding a claim unless VA can grant the claim with less evidence than requested.
A substantially complete claim must be submitted Original application on appropriate VA form Claimants name Claimants relationship to the veteran, if applicable Benefit claimed Must be signed AND IT MUST INCLUDE>>>>>>>
SERVICEMEDICAL sufficient service information for VA to verify the claimed service benefit claimed disability(ies) for which the benefit is claimed medical evidence or directions to that evidence (21-4142 for private medical) Lay statements/evidence
DEPENDENCYINCOME Evidence sufficient to establish all dependents claimed statement of income and net worth for non-service connected disability, death pension or parents' DIC.
If the application is not substantially complete, VA is obligated to return it to the claimant with instructions on what is lacking.
Notice to claimant Obtain Federal records Obtain non-federal records (with certain restrictions) Request exam or opinion
Submit substantially complete application Provide release for VA to obtain private records
No complete application No legal standing Claim is inherently not credible Claimant fails to cooperate Claimant fails to notify VA of relevant records 21
VA can grant on whats there All evidence is of record VA notified records arent available Further attempts would be futile Records have no bearing on issue
The claimant will be informed of VA decision by letter. The notification includes: The decision. The evidence considered. How the decision will affect their benefits. Appeal Rights.
Proof of service Continuity Request service medical records from veteran VA medical center records Medical evidence from private provider
Reopened claim New and material evidence Prior denial of the claimed condition was due to a lack of a current disability Prior denial of the claimed condition was due to a lack of evidence concerning the disability, incident, event or exposure alleged to be related to the current disability Prior denial for the claimed condition was due to a lack of a nexus
PTSD Agent Orange Unemployability - Employment information (employer)
Pension War time service 90 day service 24 months after: 9-7-80 for enlisted 10-16-81 for officers Medical evidence for pension Special Monthly Pension
Application must contain sufficient information for VA to verify claimed service Minimum service requirements – 38 CFR 3.12a
VA will verify service if dates only are furnished. An original, signed copy of the DD-214 is the best source. A copy that was filed with the custodian of public records is acceptable. Multiple periods require…
Original, new claims, reopened claims and claims for increase will require some type of medical evidence. Service Medical Records (SMRs) are a vital piece of evidence in all SC claims. VCAA says VAs duty to assist includes obtaining SMRs. If claimant has copies or originals of SMRs get them, copy and submit with claim!!!
At Reserve Center if active. Get name and address. Request claimants assistance. At discharge from Reserves, SMRs eventually go to NPRC or RMC.
NG records are in the custody of the Adjutant General of the state in which the NG service was/is performed. All NG records must be requested individually from the states AG office in writing.
Do not request copies of the veterans SMRs from NPRC when you submit a claim to the VA; the VA claim will be delayed while NPRC responds to the request. The VA claim could be delayed for six months or more.
34 Time lost from work Evidence that the veteran sought medical treatment for his/her symptoms Relevant observations such as changes in the veterans Appearance Physical abilities Mental or emotional status
35 A lay persons statement regarding the veterans complaints, when they began, how long they lasted, and the severity of the observed symptoms/illness, may be sufficient to satisfy the requirements for objective indications of chronic disability.
36 A lay statement that is based on personal observation or experience is credible if the Person making the statement is/was in a position to know the facts attested to Statement is sufficiently specific to address the facts, and Statement is not contradicted by evidence of record that is more credible.
38 CFR 3.159(a)(2) Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and Conveys matters that can be observed and described by a lay person.
38 When combined with an examining physicians inability to make a diagnosis, the veterans testimony that he/she is experiencing the symptoms described may be sufficient to establish the existence of the illness. Statement of combat vet carries significant weight. (38 CFR 3.304(d))
38 CFR 3.304(d) Satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service even though there is no official record of such incurrence or aggravation.
List disability(ies) upon which claim is based Identify dates and places of treatment For private treatment preferably provide copies of treatment records or submit 21-4142
VA is required to obtain all Federal records they are aware of that are relevant to the claim. VA is required to attempt to obtain all non- Federal records that the claimant directs VA to. It is ultimately the claimants responsibility to submit non-Federal records VA cannot obtain.
There is no automatic search for VA Medical Center records. Veteran must tell the VA the place and approximate dates of treatment. Various categories of VA medical evidence
VA must attempt to obtain records held by other Federal agencies. HOWEVER, these must be identified with the claim