What Happens to My Claim After it Gets Submitted

Many Veterans wonder “What happens to my claim once it’s submitted?”  The standard government answer is “It depends on the current VA pending workload and the complexity of your claim.”  What does that really mean, and how can I make my claim stand out to go faster?

What You Need to Know on How VA Claims Processing Works

The Veterans Benefits Administration (VBA) is the arm of the VA in charge of all things benefits related for VA.  In each Regional Office, there is a Claims Team that works Original Claims that are submitted via Fax, Mail, or Electronically (via eBenefits or an approved VSO, CVSO, or Attorney).  Once a Claim is submitted, it is indexed and prepared by a Claims Assistant (CA) for placement into the work queue for the Veteran’s Service Representative (VSR), who does the majority of the work on the Claims.  The VSR does all of the work to prepare it for a decision, sends it to a Senior VSR for review, and is sent to a Rating VSR for approval.  Once that is approved, a Rating Award Letter is generated and sent to the Veteran and the digital record is updated.

The VSRs are on a point system for everything they do, and have a daily, weekly, and monthly quota.  Closing a file by recommending an award action is the highest point total for them.  While the VA has a mandated “Duty to Assist” the Veteran in the assembly and processing of their claim, that is the lowest point value in the quota system.  If a Claim requires too much work, it will be pushed aside for another claim that is easier to process in order for the VSR to make their point quotas.  Members of our team saw that first-hand when they worked for VBA in in recent years. It sucks for both sides (the VSR & Veteran), but knowing how to approach it can help you in the end.

What does VBA consider to be “Complex”

VBA classifies a Claim as “Complex” if a Claim has multiple claimed conditions and/or supporting documentation is incomplete.  Incomplete documentation can be anything from not providing proof of military service, not providing full medical documentation, to not defining what conditions you’re claiming.  These will result in your claim being pushed aside for easier to work on claims and your claim taking longer to be worked on, and subsequently, decided on.

How Can I Make My Claim Not Be Complex

The goal is to make the VSR’s job easy so they will snag your file quicker and do yours first before someone else’s that may be less complicated.  The goal is to make the VSR at VA that opens your file look at it and say “this looks like a claim I can look through and finish quickly.” Make it so that the dots of what you’re claiming and the evidence to support it are easily connected & supported – that’s how to make a claim more appealing to a VSR to work on first, and hopefully, produce a more successful outcome.  Here are some tips on how to organize your files in your claim:

  • Organize the documents in a way where everything is separated by each claimed condition.
  • In each file, start with when the first sign of the condition when it was documented during service
  • Proceed chronologically with each reference to that condition until present day
  • Label each file with the condition name as it is listed in the Schedule of Ratings, Citing the Condition Number and Name (for example: 5242 – Degenerative arthritis of the spine)
  • Again, this is to make the VSR’s job easier.

No matter which way you choose to submit your claim, organizing it in a way to make it complete and more appealing to a VSR to complete will work well not only for you, but the VSR as well.  As far as the best way to submit your claim (self-represent, Veteran Service Organization, County Veteran Service Officer; paper by mail, fax, electronic), it all depends on what you feel most comfortable with.  We will cover that topic in another post.

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The Secretary and Undersecretary Want to Hear From You – Does It Work?

A few months ago, the new Secretary of the VA, Robert McDonald, and the Undersecretary for Benefits (USB), Allison Hickey, decided that that wanted to hear directly from Veterans who have experience long delays in any VA Services.  To find out what was going on, they publically published their contact information so that Veterans could contact them.

Most of our team here were skeptical of this at first, thinking it was nothing more than lip service for the media to pick up.  As things have moved forward, we have been hearing of more cases of contacting them that have produced fast and successful results.  Recently, several members of the VBRG Team have used these lines of communication, and got immediate contact back from the USB, who also copied in the Director of the Regional Offices involved, and made fast work of the issues at hand, resolving most long-standing issues in under a week.  The USB has made it her mission to tackle any long backlogged claims (claims over 125 days since filing) and delayed appeals and get them moving forward and completed.  The USB has assembled an investigative team to tackle any and all inquiries.

The question is how do I contact them effectively?

  • First off, Keep It Respectful – they are more likely to help a Veteran who is being calm, cool, and collected than one who is just yelling through the email.
  • Provide as Many Details as Possible – Keep a Timeline of Contact on your case – exams, phone calls, letters, and/or major events.They want to help you, but they also want to take the information and help others by making improvements in processes.
  • Let Them Know If you’re experiencing hardships because of delays in your case – Are At-Risk of losing your home, unable to pay utility bills, facing bankruptcy, debt collections, repossessions?If so, let them know.  Where normal hardship letters seem to fall on deaf ears in the past, going right to the top has produced results in many cases.

If they take the time to respond, respond back to let them know you have seen it, and again, keep it respectful.  Here is a sanitized response that one Veteran received from the USB 9 hours after emailing her:

[Veteran],

That made me tired just reading all the back and forth you have endured.  Let me ask [Regional Office Director] to get an expert on this asap and lets get this resolved with minimal back and forth moving forward.

[Regional Office Director] – please let me know the way forward.

Allison

If you feel that your case has been bogged down and want to see something happen, this is the way to go.  Below is a graphic of the contact information for the Secretary and USB:

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We wish you all the best of luck, and we will keep the information coming.

 

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Presumptive Conditions for Agent Orange Exposure

We’ve talked about Presumptive Conditions and how they relate to Disability Compensation, mentioning that Agent Orange exposure was one of the first scenarios that had presumptive conditions applied to.

The process has 2 steps in the process to prepare a claim for Agent Orange Presumptive Condition(s):

  • See if you have one of the Presumptive Conditions associated with Agent Orange Exposure
    • AL Amyloidosis
    • Chronic B-cell Leukemias
    • Chloracne (or similar acneform disease)
    • Diabetes Mellitus Type 2
    • Hodgkin’s Disease
    • Ischemic Heart Disease
    • Multiple Myeloma
    • Non-Hodgkin’s Lymphoma
    • Parkinson’s Disease
    • Peripheral Neuropathy, Early-Onset
    • Porphyria Cutanea Tarda
    • Prostate Cancer
    • Respiratory Cancers (includes lung cancer)
    • Soft Tissue Sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma)
    • For more information including details on any of these conditions, go to http://www.publichealth.va.gov/exposures/agentorange/conditions/index.asp

Also, there are conditions that can be claimed if a Veteran’s child shows any of the following conditions:
  • Spina Bifida
  • Birth Defects of in children of women Veterans
    • Achondroplasia
    • Cleft lip and cleft palate
    • Congenital heart disease
    • Congenital talipes equinovarus (clubfoot)
    • Esophageal and intestinal atresia
    • Hallerman-Streiff syndrome
    • Hip dysplasia
    • Hirschprung’s disease (congenital megacolon)
    • Hydrocephalus due to aqueductal stenosis
    • Hypospadias
    • Imperforate anus
    • Neural tube defects
    • Poland syndrome
    • Pyloric stenosis
    • Syndactyly (fused digits)
    • Tracheoesophageal fistula
    • Undescended testicle
    • Williams syndrome
For more on these conditions in children of Veterans, go to http://www.publichealth.va.gov/exposures/agentorange/birth-defects/index.asp

If you have a claim for an Agent Orange condition, get with a Veteran Service Organization and get their assistance.  This has been a major focus for the VA, as well as the VSOs.


Presumptive Condition for Traumatic Brain Injury Added

The VA has in the past made the decision to make certain medical conditions that are connected to a specific injury or exposure to a dangerous substance can be automatically presumed to be service-connected automatically.  The first big labeling of Presumptive Conditions was for exposure to Agent Orange during the Vietnam War.

The VA has now finalized a new round of Presumptive Conditions that are connected to Traumatic Brain Injury (TBI) that can be awarded as additional conditions for compensation ratings.  The Presumptive Conditions for TBI are:

  • Parkinson’s disease
  • Certain types of dementia including Alzheimer’s disease
  • Depression
  • Hormone deficiencies caused by changes of the hypothalamus
  • Hormone deficiencies caused by changes of the pituitary glands

With many of the presumptive conditions, these may not present themselves right away.  In fact, in most cases with Agent Orange, can take years or decades to show any signs of these conditions.

If you have a TBI and have any of these presumptive conditions, you should contact either your VA Regional Office or your representation (lawyer or Veteran Service Organization).

Please spread the word on these major changes!

Individual Unemployability – What is it and How Does it Work?

One of the biggest questions about Veterans Benefits that always comes up in regards to Total Disability Individual Unemployability (TDIU) status when it comes to Disability Compensation.  Here’s what you need to know:

What is Individual Unemployability?

  • Individual Unemployability (IU) is a part of VA’s disability compensation program that allows VA to pay certain Veterans compensation at the 100% rate, even though VA has not rated their service-connected disabilities at the 100% level.

What is the Eligibility Criteria for Individual Unemployability?

  • A Veteran must be unable to maintain substantially gainful employment as a result of his/her service-connected disabilities. Additionally, a Veteran must have:
    • One service-connected disability rated at 60 percent or more, OR
    • Two or more service-connected disabilities, at least one disability rated at 40 percent or more with a combined rating of 70 percent or more.

Can I Work?

  • Veterans who are in receipt of Individual Unemployability benefits may work as long as it is not considered substantially gainful employment. The employment must be considered marginal employment.

What is “substantially gainful employment?”

  • Substantially gainful employment is defined as employment at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the Veteran resides. 

What is the definition of “Marginal Employment?”

  • Marginal employment is generally deemed to exist when a Veteran’s earned income does not exceed the amount established by the U.S. Census Bureau as the poverty level for the Veteran only. For more information on the U.S. Census Bureau’s poverty thresholds, see http://www.census.gov/hhes/www/poverty/data/threshld/index.html

Can I be Self-Employed or run my own business when it comes to TDIU?

  • ‘Self-employment’ as a factor matters most for veteran’s with a psychological component to their claims and unemployability.  Self-employment is inherently ‘protected’ employment.  For example, if I have bad PTSD, I may be able to maintain employment as a computer consultant…I would make my own hours and have no interpersonal interaction with others…thus keeping me employed but by my own rules.  This veteran/person would be able to maintain employment but only under these circumstances.  They would fail miserably if they had to punch a time clock and have normal office place socialization and interactions.  VA will deny as saying…he’s employed.  But in reality, he’s only employed because he is his own boss and thus able to make his own rules.

Sources:

Can Your Senator or Representative Help in Your Claim Battle?

In dealing with the frustrations of dealing with the VA Disability Claim process, some Veterans are left trying to figure out any way to make things move along faster.  The best way to do so – contact your Senator or Representative and speak with their office.

Your elected officials can send an official inquiry on you claim, which can elevate your claim in priority.  The VA prefers not to be on the radar screen of members of Congress, so if a member of Congress sends an inquiry to VA on your claim, they will want to act faster so that they get off the “Congressional Radar” and go back to business as usual.
Your Senator or Representative will want to help you.  Why, you ask?  If they can help your case in a positive way, they feel that they will get your vote when they are up for re-election.  Some members of Congress are more Pro-Veteran than others, so you will want to find out which of your 3 members of Congress will be more receptive to your situation.
Have any of you had interaction and experience with working with a member of Congress on your claim issues?  Please share with us so we can share it with all of our readers.

Guest Blogger – Kent’s Experience with VA Claims

I’d like to welcome the first of hopefully many Guest Bloggers give their take and insight on the VA Claims Process.  With that, let’s turn it over to Kent, who contacted us wanting to share his story.

                          How to Navigate the V.A. and Keeping it Non-Adversarial

After my third back surgery it became apparent to me that my days of physical labor in manufacturing was drawing to a close, and the need for securing the future of my family and our standard of living was at hand.
 
I was home recuperating after my third surgery when I happened across the veterans friendly website hosted by Jim Strickland, while I was looking up my wife’s 90 year old grandfathers WW II combat unit for him. It was then I had my epiphany and realized that I had been duped by the V.A. nearly twenty years earlier after my ETS from active duty in the Army.

I am a Gulf War I era vet, and I was injured while serving as a gunner in an artillery unit (13-B). I had fractured my spine after being rocked off the back of my 109 howitzer onto the metal spades during a fire mission. As we all know “toughing it out and driving on to accomplish the mission” is the first and foremost of our training and job while we serve. Injury is dealt with until we just can’t move anymore. This is exactly what happened to me. My medical care while in the army was fundamental and basic at best. Hot packs/therapy and Motrin, it wasn’t until weeks later that an x-ray was done and the fracture(s) had healed, did I know the extent of my injury.

I remember during my out-processing in 1992 being asked “if I had any injuries?” and pretty much shrugged it off, being eager to get on with my life and start my civilian job. I went as advised to the vet center in Jackson, Mississippi after I relocated for my new job to sign up for my post-military benefits etc. At that time I mentioned to the V.A. counselor I had a severe back issue and wanted to know about medical care. Knowing that most soldiers don’t have access to the CFR (code of federal regulations) this counselor promptly told me, “oh you don’t want the V.A. giving you medical care, you will need to go to Dallas (several hundred miles away) and will be there for a month or more. You have a good job, just let your insurance handle it”. So I did just that, for the next seventeen years.

I learned from Jim Strickland’s A-Z website (http://www.jimstrickland912.com/everything I needed to know about filing my claim and getting the benefits that I needed to preserve and maintain my family’s standard of living. I won a fair award and rating from the V.A. and also entered the Chapter 31 program. I have earned my bachelor’s degree from a top-tier business college, attending one night a week, and I am now working on my MBA, all through the V.A.

The first thing you must do is determine if you have an injury that occurred or was pre-existing and subsequently aggravated by your military service. To do this you will need a copy of your SMR’s (service medical records). Then you need to learn as much as you can about your injury. Do this by reading your medical records, military and civilian, the CFR, and all your doctor’s visits notes, post military. In my case I had all my doctors that treated me for back issues in the previous seventeen years write me a letter stating they had reviewed my SMR’s and my civilian medical records and agreed that my condition was “more likely than not” related to the injury while in service. This is called a “NEXUS” and it’s a vital step in getting your benefits.

When you have this “Nexus” letter(s) in hand, and your SMR’s, you can now start your claim. Download the form from VA.GOV (form 21-546) make a separate folder and keep copies of everything. ALWAYS mail to your regional office certified with return receipt, ALWAYS. No phone calls, no fax, those get lost or forgotten. It took me exactly one year to the day to get my claim resolved. I did everything myself. If you can navigate the web you can handle this.

To re-cap all of this I will simply state the following;
  • Nobody cares about your claim but you!
  • You must have an honorable discharge.
  • Read all you can from the web about filing a disability claim with the VA
  • Read everything Jim Strickland has ever written about filing a claim, his A-Z guide is the Holy Grail.
  • Learn the CFR.
  • Learn to navigate VA.GOV
  • Read the VA.GOV claims appeals that are similar to your claim
  • Study the forms from the V.A. before you fill them out and mail them.
  • Make copies of everything and keep it organized.
  • Contact a vet that has successfully completed a claim, they will gladly help a deserving brother.
  • Learn everything you can about your injury or condition.
  • Get letters from old military buddies that witnessed your injury.
  • Get unit records if needed.
  • PREP, PREP, PREP
  • Anytime the V.A. contacts you after you file your claim, act on the request and follow through, the clock starts ticking and you can really create problems by not acting on the request.
  • Never, I repeat NEVER get rude or cuss any VA employee that you come into contact with during this journey; doing so can complicate things in a completely unnecessary way. There are other more effective ways to handle issues.
  • Be patient, take up a hobby, this will take time, do thing right the first time is the only thing to keep thing moving.
  • This process is set-up to be non-adversarial, but you must educate yourself, and think of this as a second part time job.

    Thanks for sharing, Ken!  I encourage all of our readers that would like to share their stories and tips to let us know.  This a page For Veterans and their supporters, By Veterans an their supporters.